American Diabetic Association 2011

P O S I T I O N
S T A T E M E N T
Standards of Medical Care in Diabetes2011

AMERICAN DIABETES ASSOCIATION
CONTENTS
I. CLASSIFICATION AND DIAGNOSIS
OF DIABETES, p. S12
A. Classification of diabetes
B. Diagnosis of diabetes
C. Categories of increased risk for diabetes (prediabetes)
II. TESTING FOR DIABETES IN ASYMPTOMATIC PATIENTS, p. S13
A. Testing for type 2 diabetes and risk
of future diabetes in adults
B. Testing for type 2 diabetes in children
C. Screening for type 1 diabetes
III. DETECTION AND DIAGNOSIS OF
GESTATIONAL DIABETES MELLITUS, p. S15
IV. PREVENTION/DELAY OF TYPE 2
DIABETES, p. S16
V. DIABETES CARE, p. S16
A. Initial evaluation
B. Management
C. Glycemic control
1. Assessment of glycemic control
a. Glucose monitoring
b. A1C
2. Glycemic goals in adults
D. Pharmacologic and overall approaches to treatment
1. Therapy for type 1 diabetes
E. Diabetes self-management education
F. Medical nutrition therapy
G. Physical activity
H. Psychosocial assessment and care
I. When treatment goals are not met
J. Hypoglycemia
K. Intercurrent illness
L. Bariatric surgery
M. Immunization
VI. PREVENTION AND MANAGEMENT
OF DIABETES COMPLICATIONS, p.
S27
A. Cardiovascular disease
1. Hypertension/blood pressure
control
2. Dyslipidemia/lipid management
3. Antiplatelet agents
4. Smoking cessation
5. Coronary heart disease screening and treatment
B. Nephropathy screening and treatment
C. Retinopathy screening and treatment
D. Neuropathy screening and treatment
E. Foot care
VII. DIABETES CARE IN SPECIFIC POPULATIONS, p. S38
A. Children and adolescents
1. Type 1 diabetes
Glycemic control
a. Screening and management of
chronic complications in children and adolescents with
type 1 diabetes
i. Nephropathy
ii. Hypertension
iii. Dyslipidemia
iv. Retinopathy
v. Celiac disease
vi. Hypothyroidism
b. Self-management
c. School and day care
d. Transition from pediatric to
adult care
2. Type 2 diabetes
3. Monogenic diabetes syndromes
B. Preconception care
C. Older adults
D. Cystic fibrosisrelated diabetes
VIII. DIABETES CARE IN SPECIFIC
SETTINGS, p. S43
A. Diabetes care in the hospital
1. Glycemic targets in hospitalized
patients
2. Anti-hyperglycemic agents in
hospitalized patients
3. Preventing hypoglycemia
Originally approved 1988. Most recent review/revision October 2010.

DOI: 10.2337/dc11-S011
2011 by the American Diabetes Association. Readers may use this article as long as the work is properly
cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.
org/licenses/by-nc-nd/3.0/ for details.
care.diabetesjournals.org
4. Diabetes care providers in the

hospital
5. Self-management in the hospital
6. Diabetes self-management education in the hospital
7. Medical nutrition therapy in the
hospital
8. Bedside blood glucose monitoring
9. Discharge planning
IX. STRATEGIES FOR IMPROVING DIABETES CARE, p. S46
iabetes is a chronic illness that requires continuing medical care and

ongoing patient self-management
education and support to prevent acute
complications and to reduce the risk of
long-term complications. Diabetes care is
complex and requires that many issues,
beyond glycemic control, be addressed. A
large body of evidence exists that supports a range of interventions to improve
diabetes outcomes.
These standards of care are intended
to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes
care, general treatment goals, and tools to
evaluate the quality of care. While individual preferences, comorbidities, and
other patient factors may require modification of goals, targets that are desirable
for most patients with diabetes are provided. These standards are not intended
to preclude clinical judgment or more extensive evaluation and management of the
patient by other specialists as needed.
For more detailed information about
management of diabetes, refer to references 13.
The recommendations included are
screening, diagnostic, and therapeutic actions that are known or believed to favorably affect health outcomes of patients
with diabetes. A grading system (Table 1),
developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and
codify the evidence that forms the basis
for the recommendations. The level of evidence that supports each recommenda-
DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011
S11
Standards of Medical Care

Table 1ADA evidence grading system for clinical practice recommendations
Level of
evidence
A
Description
Clear evidence from well-conducted, generalizable, randomized controlled
trials that are adequately powered, including:
Evidence from a well-conducted multicenter trial
Evidence from a meta-analysis that incorporated quality ratings in the
analysis
Compelling nonexperimental evidence, i.e., all or none rule developed
by Center for Evidence Based Medicine at Oxford
Supportive evidence from well-conducted randomized controlled trials
that are adequately powered, including:
Evidence from a well-conducted trial at one or more institutions
Evidence from a meta-analysis that incorporated quality ratings in the
analysis
Supportive evidence from well-conducted cohort studies
Evidence from a well-conducted prospective cohort study or registry
Evidence from a well-conducted meta-analysis of cohort studies
Supportive evidence from a well-conducted case-control study
Supportive evidence from poorly controlled or uncontrolled studies
Evidence from randomized clinical trials with one or more major or
three or more minor methodological flaws that could invalidate the
results
Evidence from observational studies with high potential for bias (such
as case series with comparison to historical controls)
Evidence from case series or case reports
Conflicting evidence with the weight of evidence supporting the
recommendation
Expert consensus or clinical experience
tion is listed after each recommendation

using the letters A, B, C, or E.
These standards of care are revised
annually by the ADAs multidisciplinary
Professional Practice Committee, incorporating new evidence. Members of the
Professional Practice Committee and their
disclosed conflicts of interest are listed on
page S97. Subsequently, as with all Position Statements, the standards of care are
reviewed and approved by the Executive
Committee of ADAs Board of Directors.
I. CLASSIFICATION AND
DIAGNOSIS OF DIABETES
A. Classification of diabetes
The classification of diabetes includes
four clinical classes:
Type 1 diabetes (results from -cell destruction, usually leading to absolute

insulin deficiency)
Type 2 diabetes (results from a progressive insulin secretory defect on the
background of insulin resistance)
Other specific types of diabetes due to
other causes, e.g., genetic defects in
-cell function, genetic defects in insu-
S12
lin action, diseases of the exocrine pancreas (such as cystic fibrosis), and drugor chemical-induced (such as in the
treatment of HIV/AIDS or after organ
transplantation)
Gestational diabetes mellitus (GDM)
(diabetes diagnosed during pregnancy
that is not clearly overt diabetes)
Some patients cannot be clearly classified

as having type 1 or type 2 diabetes. Clinical presentation and disease progression
vary considerably in both types of diabetes. Occasionally, patients who otherwise
have type 2 diabetes may present with ketoacidosis. Similarly, patients with type 1
diabetes may have a late onset and slow
(but relentless) progression of disease despite having features of autoimmune disease. Such difficulties in diagnosis may
occur in children, adolescents, and
adults. The true diagnosis may become
more obvious over time.
B. Diagnosis of diabetes
For decades, the diagnosis of diabetes was
based on plasma glucose criteria, either
the fasting plasma glucose (FPG) or the
2-h value in the 75-g oral glucose tolerance test (OGTT) (4).
In 2009, an International Expert
Committee that included representatives
of the ADA, the International Diabetes
Federation (IDF), and the European Association for the Study of Diabetes
(EASD) recommended the use of the A1C
test to diagnose diabetes, with a threshold
of 6.5% (5), and ADA adopted this criterion in 2010 (4). The diagnostic test
should be performed using a method that
is certified by the National Glycohemoglobin Standardization Program (NGSP)
and standardized or traceable to the Diabetes Control and Complications Trial
(DCCT) reference assay. Point-of-care
A1C assays are not sufficiently accurate at
this time to use for diagnostic purposes.
Epidemiologic datasets show a similar relationship between A1C and risk of
retinopathy as has been shown for the
corresponding FPG and 2-h plasma glucose thresholds. The A1C has several advantages to the FPG and OGTT, including
greater convenience, since fasting is not
required; evidence to suggest greater preanalytical stability; and less day-to-day
perturbations during periods of stress and
illness. These advantages must be balanced by greater cost, the limited availability of A1C testing in certain regions of
the developing world, and the incomplete
correlation between A1C and average glucose in certain individuals. In addition,
A1C levels can vary with patients ethnicity (6) as well as with certain anemias and
hemoglobinopathies. For patients with an
abnormal hemoglobin but normal red cell
turnover, such as sickle cell trait, an A1C
assay without interference from abnormal
hemoglobins should be used (an updated
list is available at www.ngsp.org/interf.
asp). For conditions with abnormal red
cell turnover, such as pregnancy, recent
blood loss or transfusion, or some anemias, the diagnosis of diabetes must employ glucose criteria exclusively.
The established glucose criteria for
the diagnosis of diabetes (FPG and 2-h
PG) remain valid as well (Table 2). Just as
there is less than 100% concordance between the FPG and 2-h PG tests, there is
not perfect concordance between A1C
and either glucose-based test. Analyses of
National Health and Nutrition Examination Survey (NHANES) data indicate that,
assuming universal screening of the undiagnosed, the A1C cut point of 6.5%
identifies one-third fewer cases of undiagnosed diabetes than a fasting glucose cut
point of 126 mg/dl (7.0 mmol/l) (7).
Position Statement
Table 2Criteria for the diagnosis of
diabetes
A1C 6.5%. The test should be performed
in a laboratory using a method that is
NGSP certified and standardized to the
DCCT assay.*
or
FPG 126 mg/dl (7.0 mmol/l). Fasting is
defined as no caloric intake for at least
8 h.*
or
2-h plasma glucose 200 mg/dl (11.1
mmol/l) during an OGTT. The test should
be performed as described by the World
Health Organization, using a glucose load
containing the equivalent of 75 g
anhydrous glucose dissolved in water.*
or
In a patient with classic symptoms of
hyperglycemia or hyperglycemic crisis, a
random plasma glucose 200 mg/dl (11.1
mmol/l)
*In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing.
However, in practice, a large portion of

the diabetic population remains unaware
of their condition. Thus, the lower sensitivity of A1C at the designated cut point
may well be offset by the tests greater
practicality, and wider application of a
more convenient test (A1C) may actually
increase the number of diagnoses made.
As with most diagnostic tests, a test
result diagnostic of diabetes should be repeated to rule out laboratory error, unless
the diagnosis is clear on clinical grounds,
such as a patient with a hyperglycemic
crisis or classic symptoms of hyperglycemia and a random plasma glucose 200
mg/dl. It is preferable that the same test be
repeated for confirmation, since there will
be a greater likelihood of concurrence in
this case. For example, if the A1C is 7.0%
and a repeat result is 6.8%, the diagnosis
of diabetes is confirmed. However, if two
different tests (such as A1C and FPG) are
both above the diagnostic thresholds, the
diagnosis of diabetes is also confirmed.
On the other hand, if two different
tests are available in an individual and the
results are discordant, the test whose result is above the diagnostic cut point
should be repeated, and the diagnosis is
made on the basis of the confirmed test.
That is, if a patient meets the diabetes criterion of the A1C (two results 6.5%) but
not the FPG (126 mg/dl or 7.0 mmol/l),
or vice versa, that person should be considered to have diabetes.
Since there is preanalytic and analytic
variability of all the tests, it is also possible

that when a test whose result was above
the diagnostic threshold is repeated, the
second value will be below the diagnostic
cut point. This is least likely for A1C,
somewhat more likely for FPG, and most
likely for the 2-h PG. Barring a laboratory
error, such patients are likely to have test
results near the margins of the threshold
for a diagnosis. The healthcare professional might opt to follow the patient
closely and repeat the testing in 3 6
months.
The current diagnostic criteria for diabetes are summarized in Table 2.
C. Categories of increased risk for
diabetes (prediabetes)
In 1997 and 2003, The Expert Committee
on Diagnosis and Classification of Diabetes Mellitus (8,9) recognized an intermediate group of individuals whose glucose
levels, although not meeting criteria for
diabetes, are nevertheless too high to be
considered normal. These persons were
defined as having impaired fasting glucose (IFG) (FPG levels 100 125 mg/dl
[5.6 6.9 mmol/l]) or impaired glucose
tolerance (IGT) (2-h PG values in the
OGTT of 140 199 mg/dl [7.8 11.0
mmol/l]). It should be noted that the
World Health Organization (WHO) and a
number of other diabetes organizations
define the cutoff for IFG at 110 mg/dl (6.1
mmol/l).
Individuals with IFG and/or IGT have
been referred to as having prediabetes, indicating the relatively high risk for the future development of diabetes. IFG and
IGT should not be viewed as clinical entities in their own right but rather risk
factors for diabetes as well as cardiovascular disease (CVD). IFG and IGT are associated with obesity (especially
abdominal or visceral obesity), dyslipidemia with high triglycerides and/or low
HDL cholesterol, and hypertension.
As is the case with the glucose measures, several prospective studies that
used A1C to predict the progression to
diabetes demonstrated a strong, continuous association between A1C and subsequent diabetes. In a systematic review of
44,203 individuals from 16 cohort studies with a follow-up interval averaging 5.6
years (range 2.8 12 years), those with an
A1C between 5.5 and 6.0% had a substantially increased risk of diabetes with
5-year incidences ranging from 9 25%.
An A1C range of 6.0 6.5% had a 5-year
risk of developing diabetes between 25
50% and relative risk 20 times higher
Table 3Categories of increased risk for diabetes (prediabetes)*

FPG 100125 mg/dl (5.66.9 mmol/l): IFG
or
2-h plasma glucose in the 75-g OGTT 140
199 mg/dl (7.811.0 mmol/l): IGT
or
A1C 5.76.4%
*For all three tests, risk is continuous, extending
below the lower limit of the range and becoming
disproportionately greater at higher ends of the
range.
compared with an A1C of 5.0% (10). In a

community-based study of black and
white adults without diabetes, baseline
A1C was a stronger predictor of subsequent diabetes and cardiovascular events
than fasting glucose (11). Other analyses
suggest that an A1C of 5.7% is associated
with diabetes risk similar to that of the
high-risk participants in the Diabetes Prevention Program (DPP).
Hence, it is reasonable to consider an
A1C range of 5.7 6.4% as identifying individuals with high risk for future diabetes, a state that may be referred to as
prediabetes (4). As is the case for individuals found to have IFG and IGT, individuals with an A1C of 5.7 6.4% should be
informed of their increased risk for diabetes as well as CVD and counseled about
effective strategies to lower their risks (see
IV. PREVENTION/DELAY OF TYPE 2 DIABETES). As
with glucose measurements, the continuum of risk is curvilinearas A1C rises,
the risk of diabetes rises disproportionately (10). Accordingly, interventions
should be most intensive and follow-up
particularly vigilant for those with A1Cs
above 6.0%, who should be considered to
be at very high risk.
Table 3 summarizes the categories of
increased risk for diabetes.
II. TESTING FOR DIABETES
IN ASYMPTOMATIC
PATIENTS
Recommendations
Testing to detect type 2 diabetes and
assess risk for future diabetes in asymptomatic people should be considered in
adults of any age who are overweight or
obese (BMI 25 kg/m2) and who have
one or more additional risk factors for
diabetes (Table 4). In those without
these risk factors, testing should begin
at age 45 years. (B)
If tests are normal, repeat testing carried out at least at 3-year intervals is
reasonable. (E)
S13

Table 4Criteria for testing for diabetes in
asymptomatic adult individuals
1. Testing should be considered in all adults
who are overweight (BMI 25 kg/m2*)
and have additional risk factors:
physical inactivity
first-degree relative with diabetes
high-risk race/ethnicity (e.g., African
American, Latino, Native American,
Asian American, Pacific Islander)
women who delivered a baby weighing
9 lb or were diagnosed with GDM
hypertension (140/90 mmHg or on
therapy for hypertension)
HDL cholesterol level 35 mg/dl (0.90
mmol/l) and/or a triglyceride level 250
mg/dl (2.82 mmol/l)
women with polycystic ovarian
syndrome (PCOS)
A1C 5.7%, IGT, or IFG on previous
testing
other clinical conditions associated with
insulin resistance (e.g., severe obesity,
acanthosis nigricans)
history of CVD
2. In the absence of the above criteria, testing
for diabetes should begin at age 45
years.
3. If results are normal, testing should be
repeated at least at 3-year intervals, with
consideration of more frequent testing
depending on initial results and risk
status.
*At-risk BMI may be lower in some ethnic groups.
To test for diabetes or to assess risk of

future diabetes, A1C, FPG, or 2-h 75-g
OGTT is appropriate. (B)
In those identified with increased risk
for future diabetes, identify and, if appropriate, treat other CVD risk factors.
(B)
For many illnesses, there is a major distinction between screening and diagnostic testing. However, for diabetes, the
same tests would be used for screening
as for diagnosis. Diabetes may be identified anywhere along a spectrum of clinical
scenarios ranging from a seemingly lowrisk individual who happens to have glucose testing, to a higher-risk individual
whom the provider tests because of high
suspicion of diabetes, to the symptomatic
patient. The discussion herein is primarily framed as testing for diabetes in those
without symptoms. Testing for diabetes
will also detect individuals at increased
future risk for diabetes, herein referred to
as having prediabetes.
S14
A. Testing for type 2 diabetes and

risk of future diabetes in adults
Type 2 diabetes is frequently not diagnosed until complications appear, and
approximately one-fourth of all people
with diabetes in the U.S. may be undiagnosed. The effectiveness of early identification of prediabetes and diabetes
through mass testing of asymptomatic individuals has not been proven definitively, and rigorous trials to provide such
proof are unlikely to occur. However,
mathematical modeling studies suggest
that screening independent of risk factors
beginning at age 30 or 45 years is highly
cost-effective ($11,000 per qualityadjusted life-year gained) (12). Prediabetes and diabetes meet established criteria
for conditions in which early detection is
appropriate. Both conditions are common and increasing in prevalence and impose significant public health burdens.
There is a long presymptomatic phase before the diagnosis of type 2 diabetes is
usually made. Relatively simple tests are
available to detect preclinical disease. Additionally, the duration of glycemic burden is a strong predictor of adverse
outcomes, and effective interventions exist to prevent progression of prediabetes
to diabetes (see IV. PREVENTION/DELAY OF TYPE
2 DIABETES) and to reduce risk of complications of diabetes (see VI. PREVENTION AND
MANAGEMENT OF DIABETES COMPLICATIONS).
Recommendations for testing for diabetes in asymptomatic, undiagnosed
adults are listed in Table 4. Testing should
be considered in adults of any age with
BMI 25 kg/m2 and one or more of the
known risk factors for diabetes. Because
age is a major risk factor for diabetes, testing of those without other risk factors
should begin no later than age 45 years.
Either A1C, FPG, or the 2-h OGTT is
appropriate for testing. The 2-h OGTT
identifies people with either IFG or IGT
and thus more people at increased risk for
the development of diabetes and CVD. It
should be noted that the two tests do not
necessarily detect the same individuals.
The efficacy of interventions for primary
prevention of type 2 diabetes (1319)
have primarily been demonstrated among
individuals with IGT, not for individuals
with IFG (who do not also have IGT) or
for individuals with specific A1C levels.
The appropriate interval between
tests is not known (20). The rationale for
the 3-year interval is that false negatives
will be repeated before substantial time
elapses, and there is little likelihood that
an individual will develop significant
complications of diabetes within 3 years

of a negative test result. In the modeling
study, repeat screening every 3 or 5 years
was cost-effective (12).
Because of the need for follow-up and
discussion of abnormal results, testing
should be carried out within the health
care setting. Community screening outside a health care setting is not recommended because people with positive
tests may not seek, or have access to, appropriate follow-up testing and care.
Conversely, there may be failure to ensure
appropriate repeat testing for individuals
who test negative. Community screening
may also be poorly targeted, i.e., it may
fail to reach the groups most at risk and
inappropriately test those at low risk (the
worried well) or even those already diagnosed.
B. Testing for type 2 diabetes in
children
The incidence of type 2 diabetes in adolescents has increased dramatically in the
last decade, especially in minority populations (21), although the disease remains
rare in the general pediatric population
(22). Consistent with recommendations
for adults, children and youth at increased risk for the presence or the development of type 2 diabetes should be
tested within the health care setting. The
recommendations of the ADA Consensus
Statement on Type 2 Diabetes in Children
and Youth (23), with some modifications,
are summarized in Table 5.
C. Screening for type 1 diabetes
Generally, people with type 1 diabetes
present with acute symptoms of diabetes
and markedly elevated blood glucose levels, and most cases are diagnosed soon
after the onset of hyperglycemia. However, evidence from type 1 prevention studies suggests that measurement of islet
autoantibodies identifies individuals who
are at risk for developing type 1 diabetes.
Such testing may be appropriate in highrisk individuals, such as those with prior
transient hyperglycemia or those who have
relatives with type 1 diabetes, in the context
of clinical research studies (see, for example, http://www2.diabetestrialnet.org).
Widespread clinical testing of asymptomatic low-risk individuals cannot currently
be recommended, as it would identify
very few individuals in the general population who are at risk. Individuals who
screen positive should be counseled
about their risk of developing diabetes.
Clinical studies are being conducted to
Position Statement
Table 5Testing for type 2 diabetes in
asymptomatic children
Criteria
Overweight (BMI 85th percentile for
age and sex, weight for height 85th
percentile, or weight 120% of ideal for
height)
Plus any two of the following risk factors:
Family history of type 2 diabetes in firstor second-degree relative
Race/ethnicity (Native American, African
American, Latino, Asian American,
Pacific Islander)
Signs of insulin resistance or conditions
associated with insulin resistance
(acanthosis nigricans, hypertension,
dyslipidemia, PCOS, or small-forgestational-age birth weight)
Maternal history of diabetes or GDM
during the childs gestation
Age of initiation: age 10 years or at onset of
puberty, if puberty occurs at a younger
age
Frequency: every 3 years
test various methods of preventing type 1

diabetes, or reversing early type 1 diabetes, in those with evidence of autoimmunity.
III. DETECTION AND
DIAGNOSIS OF
GESTATIONAL DIABETES
MELLITUS
Recommendations
Screen for undiagnosed type 2 diabetes
at the first prenatal visit in those with
risk factors, using standard diagnostic
criteria. (B)
In pregnant women not known to have
diabetes, screen for GDM at 24 28
weeks of gestation, using a 75-g 2-h
OGTT and the diagnostic cut points in
Table 6. (B)
Screen women with GDM for persistent
diabetes 6 12 weeks postpartum. (E)
Women with a history of GDM should
have lifelong screening for the development of diabetes or prediabetes at least
every 3 years. (E)
For many years, GDM was defined as any
degree of glucose intolerance with onset
or first recognition during pregnancy (8),
whether or not the condition persisted after pregnancy, and not excluding the possibility that unrecognized glucose
intolerance may have antedated or begun
concomitantly with the pregnancy. This
definition facilitated a uniform strategy
for detection and classification of GDM,

but its limitations were recognized for
many years. As the ongoing epidemic of
obesity and diabetes has led to more type
2 diabetes in women of childbearing age,
the number of pregnant women with undiagnosed type 2 diabetes has increased
(24). Because of this, it is reasonable to
screen women with risk factors for type 2
diabetes (Table 4) for diabetes at their initial prenatal visit, using standard diagnostic criteria (Table 2). Women with
diabetes found at this visit should receive
a diagnosis of overt, not gestational, diabetes.
GDM carries risks for the mother and
neonate. The Hyperglycemia and Adverse
Pregnancy Outcomes (HAPO) study (25),
a large-scale (25,000 pregnant women)
multinational epidemiologic study, demonstrated that risk of adverse maternal,
fetal, and neonatal outcomes continuously increased as a function of maternal
glycemia at 24 28 weeks, even within
ranges previously considered normal for
pregnancy. For most complications, there
was no threshold for risk. These results
have led to careful reconsideration of the
diagnostic criteria for GDM. After deliberations in 2008 2009, the International
Association of Diabetes and Pregnancy
Study Groups (IADPSG), an international
consensus group with representatives
from multiple obstetrical and diabetes organizations, including ADA, developed
revised recommendations for diagnosing
GDM. The group recommended that all
women not known to have diabetes undergo a 75-g OGTT at 24 28 weeks of
gestation. Additionally, the group developed diagnostic cut points for the fasting,
1-h, and 2-h plasma glucose measurements that conveyed an odds ratio for adverse outcomes of at least 1.75 compared
with the mean glucose levels in the HAPO
study. Current screening and diagnostic
strategies, based on the IADPSG statement (26), are outlined in Table 6.
These new criteria will significantly
increase the prevalence of GDM, primarily because only one abnormal value, not
two, is sufficient to make the diagnosis.
The ADA recognizes the anticipated significant increase in the incidence of GDM
to be diagnosed by these criteria and is
sensitive to concerns about the medicalization of pregnancies previously categorized as normal. These diagnostic criteria
changes are being made in the context of
worrisome worldwide increases in obesity and diabetes rates, with the intent of
Table 6Screening for and diagnosis of

GDM
Perform a 75-g OGTT, with plasma glucose
measurement fasting and at 1 and 2 h,
at 2428 weeks of gestation in women
not previously diagnosed with overt
diabetes.
The OGTT should be performed in the
morning after an overnight fast of at
least 8 h.
The diagnosis of GDM is made when any of
the following plasma glucose values are
exceeded:
Fasting 92 mg/dl (5.1 mmol/l)
1 h 180 mg/dl (10.0 mmol/l)
2 h 153 mg/dl (8.5 mmol/l)
optimizing gestational outcomes for

women and their babies.
Admittedly, there are few data from
randomized clinical trials regarding therapeutic interventions in women who will
now be diagnosed with GDM based on
only one blood glucose value above the
specified cut points (in contrast to the
older criteria that stipulated at least two
abnormal values.) Expected benefits to
their pregnancies and offspring is inferred
from intervention trials that focused on
women with more mild hyperglycemia
than identified using older GDM diagnostic criteria and that found modest benefits
(27,28). The frequency of their follow-up
and blood glucose monitoring is not yet
clear, but likely to be less intensive than
women diagnosed by the older criteria.
Additional well-designed clinical studies
are needed to determine the optimal intensity of monitoring and treatment of
women with GDM diagnosed by the new
criteria (that would not have met the prior
definition of GDM). It is important to note
that 80 90% of women in both of the
mild GDM studies (whose glucose values
overlapped with the thresholds recommended herein) could be managed with
lifestyle therapy alone.
Because some cases of GDM may represent preexisting undiagnosed type 2 diabetes, women with a history of GDM
should be screened for diabetes 6 12
weeks postpartum, using nonpregnant
OGTT criteria. Women with a history of
GDM have a greatly increased subsequent
risk for diabetes (29) and should be followed up with subsequent screening for
the development of diabetes or prediabetes, as outlined in II. TESTING FOR DIABETES IN
ASYMPTOMATIC PATIENTS.
S15

Table 7Therapies proven effective in diabetes prevention trials
Study (ref.)
Lifestyle
Finnish DPS (14)
DPP (13)
Da Qing (15)
Toranomon Study
(35)
Indian DPP (19)
Medications
DPP (13)
Population
Mean
age
Duration
(years) (years)
522 IGT, BMI 25 kg/m2

55
2,161* IGT, BMI 24 kg/m2,
51
FPG 5.3 mmol/l
259* IGT (randomized groups) 45
55
458 IGT (men), BMI 24
kg/m2
269* IGT
46
2,155* IGT, BMI 24 kg/m2,

FPG 5.3 mmol/l
Indian DPP (19)
269* IGT
STOP-NIDDM (17) 1,419 IGT, FPG 5.6 mmol/l
XENDOS (36)
3,277 BMI 30 kg/m2
DREAM (18)
5,269 IGT or IFG
Voglibose Ph-3
1,780 IGT
(37)
51
46
54
43
55
56
Intervention
(daily dose)
Incidence in
control
subjects
(%/year)
Relative risk
reduction (%)
(95% CI)
3-Year
number
needed to
treat
3.2
3
I-D&E
I-D&E
6
10.4
58 (3070)
58 (4866)
8.5
6.9
6
4
G-D&E
I-D&E
14.5
2.4
38 (1456)
67 (P 0.043)
7.9
20.6
2.5
I-D&E
23
29 (2137)
6.4
10.4
31 (1743)
13.9
23
12.4
2.4
9.1
12.0
26 (1935)
25 (1037)
37 (1454)
60 (5465)
40 (1857)
6.9
9.6
45.5
6.9
21 (1-year
Rx)
2.8
Metformin (1,700
mg)
2.5
Metformin (500 mg)
3.2
Acarbose (300 mg)
4
Orlistat (360 mg)
3.0
Rosiglitazone (8 mg)
3.0 (1-year Vogliobose (0.2 mg)
Rx)
Modified and reprinted with permission (38). Percentage points: Number needed to treat to prevent 1 case of diabetes, standardized for a 3-year period to improve
comparisons across studies. *Number of participants in the indicated comparisons, not necessarily in entire study. Calculated from information in the article. DPP, Diabetes
Prevention Program; DPS, Diabetes Prevention Study; DREAM, Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication; STOP-NIDDM, Study to
Prevent Non-Insulin Dependent Diabetes; XENDOS, Xenical in the prevention of Diabetes in Obese Subjects. I, individual; G, group; D&E, diet and exercise.
IV. PREVENTION/DELAY
OF TYPE 2 DIABETES
Recommendations
Patients with IGT (A), IFG (E), or an
A1C of 5.7 6.4% (E) should be referred to an effective ongoing support
program targeting weight loss of 7% of
body weight and increasing physical
activity to at least 150 min/week of
moderate activity such as walking.
Follow-up counseling appears to be important for success. (B)
Based on potential cost savings of diabetes prevention, such programs should be
covered by third-party payors. (E)
Metformin therapy for prevention of
type 2 diabetes may be considered in
those at the highest risk for developing
diabetes, such as those with multiple
risk factors, especially if they demonstrate progression of hyperglycemia
(e.g., A1C 6%) despite lifestyle interventions. (B)
Monitoring for the development of diabetes in those with prediabetes should
be performed every year. (E)
Randomized controlled trials have shown
that individuals at high risk for developing diabetes (those with IFG, IGT, or
both) can be given interventions that significantly decrease the rate of onset of diS16
abetes (1319). These interventions

include intensive lifestyle modification
programs that have been shown to be very
effective (58% reduction after 3 years)
and use of the pharmacologic agents metformin, -glucosidase inhibitors, orlistat,
and thiazolidinediones (TZDs), each of
which has been shown to decrease incident diabetes to various degrees. A summary of major diabetes prevention trials is
shown in Table 7.
Follow-up of all three large studies of
lifestyle intervention has shown sustained
reduction in the rate of conversion to type
2 diabetes, with 43% reduction at 20
years in the Da Qing study (30), 43% reduction at 7 years in the Finnish Diabetes
Prevention Study (DPS) (31) and 34% reduction at 10 years in the U.S. Diabetes
Prevention Program Outcomes Study
(DPPOS) (32). A cost-effectiveness analysis suggested that lifestyle interventions as
delivered in the DPP are cost-effective
(33). Group delivery of the DPP intervention in community settings has the potential to be significantly less expensive while
still achieving similar weight loss (34).
Based on the results of clinical trials
and the known risks of progression of
prediabetes to diabetes, persons with an
A1C of 5.7 6.4%, IGT, or IFG should be
counseled on lifestyle changes with goals
similar to those of the DPP (7% weight
loss and moderate physical activity of at

least 150 min/week). Regarding the more
difficult issue of drug therapy for diabetes
prevention, a consensus panel felt that
metformin should be the only drug considered (39). For other drugs, the issues of
cost, side effects, and lack of persistence
of effect in some studies led the panel to
not recommend their use for diabetes prevention. Metformin, which was significantly less effective than lifestyle in the
DPP and DPPOS, reasonably may be recommended for very-high-risk individuals
(those with risk factors for diabetes and/or
those with more severe or progressive hyperglycemia). Of note, in the DPP metformin was most effective compared to
lifestyle in those with BMI of at least 35
kg/m2 and was not significantly better
than placebo in those over age 60 years.
V. DIABETES CARE
A. Initial evaluation
A complete medical evaluation should be
performed to classify the diabetes, detect
the presence of diabetes complications,
review previous treatment and glycemic
control in patients with established diabetes, assist in formulating a management
plan, and provide a basis for continuing
care. Laboratory tests appropriate to the
evaluation of each patients medical concare.diabetesjournals.org
Position Statement
dition should be performed. A focus on
the components of comprehensive care
(Table 8) will assist the health care team to
ensure optimal management of the patient with diabetes.
B. Management
People with diabetes should receive medical care from a physician-coordinated
team. Such teams may include, but are
not limited to, physicians, nurse practitioners, physicians assistants, nurses, dietitians, pharmacists, and mental health
professionals with expertise and a special
interest in diabetes. It is essential in this
collaborative and integrated team approach that individuals with diabetes assume an active role in their care.
The management plan should be
formulated as a collaborative therapeutic alliance among the patient and family, the physician, and other members of
the health care team. A variety of strategies and techniques should be used to
provide adequate education and development of problem-solving skills in the
various aspects of diabetes management. Implementation of the management plan requires that each aspect is
understood and agreed to by the patient
and the care providers and that the goals
and treatment plan are reasonable. Any
plan should recognize diabetes selfmanagement education (DSME) and
ongoing diabetes support as an integral
component of care. In developing the
plan, consideration should be given to
the patients age, school or work schedule and conditions, physical activity,
eating patterns, social situation and
cultural factors, and presence of complications of diabetes or other medical
conditions.
C. Glycemic control
1. Assessment of glycemic control
Two primary techniques are available for
health providers and patients to assess the
effectiveness of the management plan on
glycemic control: patient self-monitoring
of blood glucose (SMBG) or interstitial
glucose, and A1C.
Table 8Components of the comprehensive diabetes evaluation

Medical history
Age and characteristics of onset of diabetes (e.g., DKA, asymptomatic laboratory finding)
Eating patterns, physical activity habits, nutritional status, and weight history; growth
and development in children and adolescents
Diabetes education history
Review of previous treatment regimens and response to therapy (A1C records)
Current treatment of diabetes, including medications, meal plan, physical activity
patterns, and results of glucose monitoring and patients use of data
DKA frequency, severity, and cause
Hypoglycemic episodes
Hypoglycemia awareness
Any severe hypoglycemia: frequency and cause
History of diabetes-related complications
Microvascular: retinopathy, nephropathy, neuropathy (sensory, including history of
foot lesions; autonomic, including sexual dysfunction and gastroparesis)
Macrovascular: CHD, cerebrovascular disease, PAD
Other: psychosocial problems*, dental disease*
Physical examination
Height, weight, BMI
Blood pressure determination, including orthostatic measurements when indicated
Fundoscopic examination*
Thyroid palpation
Skin examination (for acanthosis nigricans and insulin injection sites)
Comprehensive foot examination:
Inspection
Palpation of dorsalis pedis and posterior tibial pulses
Presence/absence of patellar and Achilles reflexes
Determination of proprioception, vibration, and monofilament sensation
Laboratory evaluation
A1C, if results not available within past 23 months
If not performed/available within past year:
Fasting lipid profile, including total, LDL and HDL cholesterol and triglycerides
Liver function tests
Test for urine albumin excretion with spot urine albumin-to-creatinine ratio
Serum creatinine and calculated GFR
Thyroid-stimulating hormone in type 1 diabetes, dyslipidemia, or women over age 50
years
Referrals
Annual dilated eye exam
Family planning for women of reproductive age
Registered dietitian for MNT
DSME
Dental examination
Mental health professional, if needed
*See appropriate referrals for these categories.
a. Glucose monitoring
Recommendations
SMBG should be carried out three or
more times daily for patients using multiple insulin injections or insulin pump
therapy. (A)
For patients using less-frequent insulin

injections, noninsulin therapies, or
medical nutrition therapy (MNT)
alone, SMBG may be useful as a guide to
the success of therapy. (E)
To achieve postprandial glucose targets, postprandial SMBG may be appropriate. (E)
When prescribing SMBG, ensure that
patients receive initial instruction in,
and routine follow-up evaluation of,
SMBG technique and their ability to use
data to adjust therapy. (E)
Continuous glucose monitoring (CGM)
in conjunction with intensive insulin

regimens can be a useful tool to lower
A1C in selected adults (age 25 years)
with type 1 diabetes. (A)
Although the evidence for A1Clowering is less strong in children,
teens, and younger adults, CGM may
be helpful in these groups. Success correlates with adherence to ongoing use
of the device. (C)
CGM may be a supplemental tool to
SMBG in those with hypoglycemia unawareness and/or frequent hypoglycemic episodes. (E)
S17

Major clinical trials of insulin-treated patients that demonstrated the benefits of
intensive glycemic control on diabetes
complications have included SMBG as
part of multifactorial interventions, suggesting that SMBG is a component of effective therapy. SMBG allows patients to
evaluate their individual response to therapy and assess whether glycemic targets
are being achieved. Results of SMBG can
be useful in preventing hypoglycemia and
adjusting medications (particularly prandial insulin doses), MNT, and physical activity.
The frequency and timing of SMBG
should be dictated by the particular needs
and goals of the patient. SMBG is especially important for patients treated with
insulin to monitor for and prevent asymptomatic hypoglycemia and hyperglycemia. For most patients with type 1
diabetes and pregnant women taking insulin, SMBG is recommended three or
more times daily. For these populations,
significantly more frequent testing may be
required to reach A1C targets safely without hypoglycemia. The optimal frequency
and timing of SMBG for patients with type
2 diabetes on noninsulin therapy is unclear. A meta-analysis of SMBG in non
insulin-treated patients with type 2
diabetes concluded that some regimen of
SMBG was associated with a reduction in
A1C of 0.4%. However, many of the studies in this analysis also included patient
education with diet and exercise counseling and, in some cases, pharmacologic intervention, making it difficult to assess the
contribution of SMBG alone to improved
control (40). Several recent trials have
called into question the clinical utility and
cost-effectiveness of routine SMBG in
noninsulin-treated patients (41 43).
Because the accuracy of SMBG is instrument and user dependent (44), it is
important to evaluate each patients monitoring technique, both initially and at
regular intervals thereafter. In addition,
optimal use of SMBG requires proper interpretation of the data. Patients should
be taught how to use the data to adjust
food intake, exercise, or pharmacological
therapy to achieve specific glycemic goals,
and these skills should be reevaluated periodically.
CGM through the measurement of interstitial glucose (which correlates well
with plasma glucose) is available. These
sensors require calibration with SMBG,
and the latter are still recommended for
making acute treatment decisions. CGM
devices also have alarms for hypo- and
S18
hyperglycemic excursions. Small studies

in selected patients with type 1 diabetes
have suggested that CGM use reduces the
time spent in hypo- and hyperglycemic
ranges and may modestly improve glycemic control. A larger 26-week randomized trial of 322 type 1 patients showed
that adults age 25 years and older using
intensive insulin therapy and CGM experienced a 0.5% reduction in A1C (from
7.6% to 7.1%) compared to usual intensive insulin therapy with SMBG (45).
Sensor use in children, teens, and adults
up to age 24 years did not result in significant A1C lowering, and there was no significant difference in hypoglycemia in any
group. Importantly, the greatest predictor
of A1C-lowering in this study for all agegroups was frequency of sensor use,
which was lower in younger age-groups.
In a smaller randomized controlled trial of
129 adults and children with baseline
A1C 7.0%, outcomes combining A1C
and hypoglycemia favored the group utilizing CGM, suggesting that CGM is also
beneficial for individuals with type 1 diabetes who have already achieved excellent
control with A1C 7.0 (46). Although
CGM is an evolving technology, emerging
data suggest that, in appropriately selected patients who are motivated to wear
it most of the time, it may offer benefit.
CGM may be particularly useful in those
with hypoglycemia unawareness and/or
frequent episodes of hypoglycemia, and
studies in this area are ongoing.
b. A1C
Recommendations
Perform the A1C test at least two times
a year in patients who are meeting treatment goals (and who have stable glycemic control). (E)
Perform the A1C test quarterly in patients whose therapy has changed or
who are not meeting glycemic goals. (E)
Use of point-of-care testing for A1C allows for timely decisions on therapy
changes, when needed. (E)
Because A1C is thought to reflect average
glycemia over several months (44), and
has strong predictive value for diabetes
complications (47,48), A1C testing
should be performed routinely in all patients with diabetes, at initial assessment
and then as part of continuing care. Measurement approximately every 3 months
determines whether a patients glycemic
targets have been reached and maintained. For any individual patient, the fre-
Table 9Correlation of A1C with average

glucose
Mean plasma glucose
A1C (%)
6
7
8
9
10
11
12
mg/dl
mmol/l
126
154
183
212
240
269
298
7.0
8.6
10.2
11.8
13.4
14.9
16.5
These estimates are based on ADAG data of 2,700

glucose measurements over 3 months per A1C measurement in 507 adults with type 1, type 2, and no
diabetes. The correlation between A1C and average
glucose was 0.92 (51). A calculator for converting
A1C results into estimated average glucose (eAG), in
either mg/dl or mmol/l, is available at http://
professional.diabetes.org/eAG.
quency of A1C testing should be

dependent on the clinical situation, the
treatment regimen used, and the judgment of the clinician. Some patients with
stable glycemia well within target may do
well with testing only twice per year,
while unstable or highly intensively managed patients (e.g., pregnant type 1
women) may be tested more frequently
than every 3 months. The availability of
the A1C result at the time that the patient
is seen (point-of-care testing) has been reported to result in increased intensification of therapy and improvement in
glycemic control (49,50).
The A1C test is subject to certain limitations. Conditions that affect erythrocyte turnover (hemolysis, blood loss) and
hemoglobin variants must be considered,
particularly when the A1C result does not
correlate with the patients clinical situation (44). In addition, A1C does not provide a measure of glycemic variability or
hypoglycemia. For patients prone to glycemic variability (especially type 1 patients, or type 2 patients with severe
insulin deficiency), glycemic control is
best judged by the combination of results
of SMBG testing and the A1C. The A1C
may also serve as a check on the accuracy
of the patients meter (or the patients reported SMBG results) and the adequacy of
the SMBG testing schedule.
Table 9 contains the correlation between A1C levels and mean plasma glucose levels based on data from the
international A1C-Derived Average Glucose (ADAG) trial utilizing frequent
SMBG and CGM in 507 adults (83% Caucasian) with type 1, type 2, and no diabecare.diabetesjournals.org
Position Statement
tes (51). The American Diabetes
Association and American Association of
Clinical Chemists have determined that
the correlation (r 0.92) is strong
enough to justify reporting both an A1C
result and an estimated average glucose
(eAG) result when a clinician orders the
A1C test. The table in previous versions of
the Standards of Medical Care in Diabetes
describing the correlation between A1C
and mean glucose was derived from relatively sparse data (one 7-point profile
over 1 day per A1C reading) in the primarily Caucasian type 1 diabetic participants in the DCCT (52). Clinicians
should note that the numbers in the table
are now different, as they are based on
2,800 readings per A1C in the ADAG
trial.
In the ADAG trial, there were no significant differences among racial and ethnic groups in the regression lines between
A1C and mean glucose, although there
was a trend toward a difference between
African/African American participants
and Caucasian ones that might have been
significant had more African/African
American participants been studied. A recent study comparing A1C with CGM
data in 48 type 1 diabetic children found
a highly statistically significant correlation between A1C and mean blood glucose, although the correlation (r 0.7)
was significantly lower than in the ADAG
trial (53). Whether there are significant
differences in how A1C relates to average
glucose in children or in African American patients is an area for further study.
For the time being, the question has not
led to different recommendations about
testing A1C or to different interpretations
of the clinical meaning of given levels of
A1C in those populations.
For patients in whom A1C/eAG and
measured blood glucose appear discrepant, clinicians should consider the possibilities of hemoglobinopathy or altered
red cell turnover, and the options of more
frequent and/or different timing of SMBG
or use of CGM. Other measures of chronic
glycemia such as fructosamine are available, but their linkage to average glucose
and their prognostic significance are not
as clear as is the case for A1C.
2. Glycemic goals in adults
Recommendations
Lowering A1C to below or around 7%
has been shown to reduce microvascular and neuropathic complications of
diabetes and, if implemented soon after
the diagnosis of diabetes, is associated

with long-term reduction in macrovascular disease. Therefore, a reasonable
A1C goal for many nonpregnant adults
is 7%. (B)
Because additional analyses from several randomized trials suggest a small
but incremental benefit in microvascular outcomes with A1C values closer to
normal, providers might reasonably
suggest more stringent A1C goals for
selected individual patients, if this can
be achieved without significant hypoglycemia or other adverse effects of
treatment. Such patients might include
those with short duration of diabetes,
long life expectancy, and no significant
CVD. (B)
Conversely, less stringent A1C goals
may be appropriate for patients with a
history of severe hypoglycemia, limited
life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, and those
with longstanding diabetes in whom
the general goal is difficult to attain despite DSME, appropriate glucose monitoring, and effective doses of multiple
glucose-lowering agents including insulin. (C)
Glycemic control is fundamental to the

management of diabetes. The DCCT (47)
(in patients with type 1 diabetes), the Kumamoto study (54), and the UK Prospective Diabetes Study (UKPDS) (55,56)
(both in patients with type 2 diabetes)
were prospective, randomized, controlled
trials of intensive versus standard glycemic control in patients with relatively recently diagnosed diabetes. These trials
showed definitively that improved glycemic control is associated with significantly decreased rates of microvascular
(retinopathy and nephropathy) and neuropathic complications. Follow up of the
DCCT cohorts in the Epidemiology of Diabetes Interventions and Complications
(EDIC) study (57,58) and of the UKPDS
cohort (59) has shown persistence of
these microvascular benefits in previously
intensively treated subjects, even though
their glycemic control has been equivalent to that of previous standard arm subjects during follow-up.
Subsequent trials in patients with
more long-standing type 2 diabetes, designed primarily to look at the role of
intensive glycemic control on cardiovascular outcomes also confirmed a benefit,
although more modest, on onset or progression of microvascular complications.
The Veterans Affairs Diabetes Trial

(VADT) showed significant reductions in
albuminuria with intensive (achieved median A1C 6.9%) compared to standard
glycemic control, but no difference in retinopathy and neuropathy (60,61). The
Action in Diabetes and Vascular Disease:
Preterax and Diamicron Modified Release
Controlled Evaluation (ADVANCE) study
of intensive versus standard glycemic
control in type 2 diabetes found a statistically significant reduction in albuminuria with an A1C target of 6.5%
(achieved median A1C 6.3%) compared
to standard therapy achieving a median
A1C of 7.0% (62). Recent analyses from
the Action to Control Cardiovascular Risk
in Diabetes (ACCORD) trial have shown
lower rates of measures of microvascular
complications in the intensive glycemic
control arm compared with the standard
arm (63,64).
Epidemiological analyses of the
DCCT and UKPDS (47,48) demonstrate a
curvilinear relationship between A1C and
microvascular complications. Such analyses suggest that, on a population level,
the greatest number of complications will
be averted by taking patients from very
poor control to fair or good control. These
analyses also suggest that further lowering
of A1C from 7 to 6% is associated with
further reduction in the risk of microvascular complications, albeit the absolute
risk reductions become much smaller.
Given the substantially increased risk of
hypoglycemia (particularly in those with
type 1 diabetes, but also in the recent type
2 trials), the concerning mortality findings in the ACCORD trial (65), and the
relatively much greater effort required to
achieve near-normoglycemia, the risks of
lower targets may outweigh the potential
benefits on microvascular complications
on a population level. However, selected
individual patients, especially those with
little comorbidity and long life expectancy (who may reap the benefits of further lowering of glycemia below 7%) may,
at patient and provider judgment, adopt
glycemic targets as close to normal as possible as long as significant hypoglycemia
does not become a barrier.
Whereas many epidemiologic studies
and meta-analyses (66,67) have clearly
shown a direct relationship between A1C
and CVD, the potential of intensive glycemic control to reduce CVD has been less
clearly defined. In the DCCT, there was a
trend toward lower risk of CVD events
with intensive control. However, 9-year
post-DCCT follow-up of the cohort has
S19

shown that participants previously randomized to the intensive arm had a 42%
reduction (P 0.02) in CVD outcomes
and a 57% reduction (P 0.02) in the
risk of nonfatal myocardial infarction
(MI), stroke, or CVD death compared
with those previously in the standard arm
(68). The benefit of intensive glycemic
control in this type 1 cohort has recently
been shown to persist for several decades
(69).
The UKPDS trial of type 2 diabetes
observed a 16% reduction in cardiovascular complications (combined fatal or nonfatal MI and sudden death) in the
intensive glycemic control arm, although
this difference was not statistically significant (P 0.052), and there was no suggestion of benefit on other CVD outcomes
such as stroke. However, 10 years of follow-up of the UKPDS cohort demonstrated, for participants originally
randomized to intensive glycemic control
compared with those randomized to conventional glycemic control, long-term reductions in MI (15% with sulfonylurea or
insulin as initial pharmacotherapy, 33%
with metformin as initial pharmacotherapy, both statistically significant) and in
all-cause mortality (13 and 27%, respectively, both statistically significant) (59).
Results of three large trials
(ACCORD, ADVANCE, and VADT) suggested no significant reduction in CVD
outcomes with intensive glycemic control
in these populations, who had more advanced diabetes than UKPDS participants. Details of these three studies are
reviewed extensively in a recent ADA position statement (70).
The glycemic control arm of
ACCORD was halted early due to the
finding of an increased rate of mortality in
the intensive arm compared with the standard arm (1.41% vs. 1.14% per year; HR
1.22 [95% CI 1.01 to 1.46]); with a similar increase in cardiovascular deaths. The
primary outcome of ACCORD (MI,
stroke, or cardiovascular death) was
lower in the intensive glycemic control
group, due to a reduction in nonfatal MI,
but this reduction was not statistically significant when the study was terminated
(65).
The potential cause of excess deaths
in the intensive group of the ACCORD
has been difficult to pinpoint. Exploratory analyses of the mortality findings of
ACCORD (evaluating variables including
weight gain, use of any specific drug or
drug combination, and hypoglycemia)
were reportedly unable to identify a clear
S20
explanation for the excess mortality in the

intensive arm. The ACCORD investigators subsequently published additional
analyses showing no increase in mortality
in the intensive arm participants who
achieved A1C levels 7% or in those who
lowered their A1C quickly after trial enrollment. In fact, the converse was observedthose at highest risk for mortality
were participants in the intensive arm
with the highest A1C levels (71).
The primary outcome of ADVANCE
was a combination of microvascular
events (nephropathy and retinopathy)
and major adverse cardiovascular events
(MI, stroke, and cardiovascular death).
Intensive glycemic control significantly
reduced the primary end point, although
this was due to a significant reduction in
the microvascular outcome, primarily development of macroalbuminuria, with no
significant reduction in the macrovascular outcome. There was no difference in
overall or cardiovascular mortality between the intensive compared with the
standard glycemic control arms (62).
The VADT randomized participants
with type 2 diabetes uncontrolled on insulin or maximal dose oral agents (median entry A1C 9.4%) to a strategy of
intensive glycemic control (goal A1C
6.0%) or standard glycemic control,
with a planned A1C separation of at least
1.5%. The primary outcome of the VADT
was a composite of CVD events. The cumulative primary outcome was nonsignificantly lower in the intensive arm (60).
Unlike the UKPDS, which was carried
out in patients with newly diagnosed diabetes, all three of the recent type 2 cardiovascular trials were conducted in
participants with established diabetes
(mean duration 8 11 years) and either
known CVD or multiple risk factors, suggesting the presence of established atherosclerosis. Subset analyses of the three
trials suggested a significant benefit of intensive glycemic control on CVD in participants with shorter duration of
diabetes, lower A1C at entry, and/or or
absence of known CVD. The DCCT-EDIC
study and the long-term follow-up of the
UKPDS cohort both suggest that intensive
glycemic control initiated soon after diagnosis of diabetes in patients with a lower
level of CVD risk may impart long-term
protection from CVD events. As is the
case with microvascular complications, it
may be that glycemic control plays a
greater role before macrovascular disease
is well developed and minimal or no role
when it is advanced. Consistent with this
concept, data from an ancillary study of

the VADT demonstrated that intensive
glycemic control was quite effective in reducing CVD events in individuals with
less atherosclerosis at baseline (assessed
by coronary calcium) but not in persons
with more extensive baseline atherosclerosis (72).
The evidence for a cardiovascular
benefit of intensive glycemic control primarily rests on long-term follow-up of
study cohorts treated early in the course
of type 1 and type 2 diabetes and subset
analyses of ACCORD, ADVANCE, and
VADT. A recent group-level metaanalysis of the latter three trials suggests
that glucose lowering has a modest (9%)
but statistically significant reduction in
major CVD outcomes, primarily nonfatal
MI, with no significant effect on mortality.
A prespecified subgroup analysis suggested that major CVD outcome reduction occurred in patients without known
CVD at baseline (HR 0.84 [95% CI 0.74
0.94]) (73). Conversely, the mortality
findings in ACCORD and subgroup analyses of VADT suggest that the potential
risks of very intensive glycemic control
may outweigh its benefits in some patients, such as those with very long duration of diabetes, known history of severe
hypoglycemia, advanced atherosclerosis,
and advanced age/frailty. Certainly, providers should be vigilant in preventing severe hypoglycemia in patients with
advanced disease and should not aggressively attempt to achieve near-normal
A1C levels in patients in whom such a
target cannot be reasonably easily and
safely achieved.
Recommended glycemic goals for
many nonpregnant adults are shown in
Table 10. The recommendations are
based on those for A1C values, with listed
blood glucose levels that appear to correlate with achievement of an A1C of 7%.
Less-stringent treatment goals may be appropriate for adults with limited life expectancies or advanced vascular disease.
Glycemic goals for children are provided
in VII.A.1.a. Glycemic control. Severe or
frequent hypoglycemia is an absolute indication for the modification of treatment
regimens, including setting higher glycemic goals.
The issue of pre- versus postprandial
SMBG targets is complex (74). Elevated
postchallenge (2-h OGTT) glucose values
have been associated with increased cardiovascular risk independent of FPG in
some epidemiological studies. In diabetic
subjects, some surrogate measures of vascare.diabetesjournals.org
Position Statement
Table 10Summary of glycemic recommendations for many nonpregnant adults with
diabetes
7.0%*
70130 mg/dl* (3.97.2 mmol/l)
180 mg/dl* (10.0 mmol/l)
A1C
Preprandial capillary plasma glucose
Peak postprandial capillary plasma glucose
Goals should be individualized based on*:
duration of diabetes
age/life expectancy
comorbid conditions
known CVD or advanced microvascular
complications
hypoglycemia unawareness
individual patient considerations
More or less stringent glycemic goals may
be appropriate for individual patients.
Postprandial glucose may be targeted if
A1C goals are not met despite reaching
preprandial glucose goals.
Postprandial glucose measurements should be made 12 h after the beginning of the meal, generally peak
levels in patients with diabetes.
cular pathology, such as endothelial dysfunction, are negatively affected by

postprandial hyperglycemia (75). It is
clear that postprandial hyperglycemia,
like preprandial hyperglycemia, contributes to elevated A1C levels, with its relative contribution being higher at A1C
levels that are closer to 7%. However, outcome studies have clearly shown A1C to
be the primary predictor of complications, and landmark glycemic control trials such as the DCCT and UKPDS relied
overwhelmingly on preprandial SMBG.
Additionally, a randomized controlled
trial in patients with known CVD found
no CVD benefit of insulin regimens targeting postprandial glucose compared
with targeting preprandial glucose (76). A
reasonable recommendation for postprandial testing and targets is that for individuals who have premeal glucose
values within target but have A1C values
above target, monitoring postprandial
plasma glucose (PPG) 12 h after the start
of the meal and treatment aimed at reducing PPG values to 180 mg/dl may help
lower A1C.
As regards goals for glycemic control
for women with GDM, recommendations
from the Fifth International WorkshopConference on Gestational Diabetes (77)
were to target maternal capillary glucose
concentrations of:
Preprandial 95 mg/dl (5.3 mmol/l)
and either
1-h postmeal 140 mg/dl (7.8
mmol/l)
or
2-h postmeal 120 mg/dl (6.7

mmol/l)
For women with preexisting type 1 or
type 2 diabetes who become pregnant, a
recent consensus statement (78) recommended the following as optimal glycemic goals, if they can be achieved without
excessive hypoglycemia:
premeal, bedtime, and overnight glucose 60 99 mg/dl (3.35.4 mmol/l)

peak postprandial glucose 100 129
mg/dl (5.4 7.1mmol/l)
A1C 6.0%
D. Pharmacologic and overall

approaches to treatment
The DCCT clearly showed that intensive
insulin therapy (three or more injections
per day of insulin, or continuous subcutaneous insulin infusion (CSII) (insulin
pump therapy) was a key part of improved glycemia and better outcomes
(47,68). At the time of the study, therapy
was carried out with short- and intermediate-acting human insulins. Despite better microvascular outcomes, intensive
insulin therapy was associated with a high
rate in severe hypoglycemia (62 episodes
per 100 patient-years of therapy). Since
the time of the DCCT, a number of rapidacting and long-acting insulin analogs
have been developed. These analogs are
associated with less hypoglycemia with
equal A1C-lowering in type 1 diabetes
(79,80).
Therefore, recommended therapy for
type 1 diabetes consists of the following

components: 1) use of multiple dose insulin injections (three to four injections
per day of basal and prandial insulin) or
CSII therapy; 2) matching of prandial insulin to carbohydrate intake, premeal
blood glucose, and anticipated activity;
and 3) for many patients (especially if hypoglycemia is a problem), use of insulin
analogs. There are excellent reviews available that guide the initiation and management of insulin therapy to achieve desired
glycemic goals (3,79,81).
Because of the increased frequency of
other autoimmune diseases in type 1 diabetes, screening for thyroid dysfunction,
vitamin B12 deficiency, or celiac disease
should be considered based on signs and
symptoms. Periodic screening in absence
of symptoms has been recommended, but
the effectiveness and optimal frequency
are unclear.
The ADA and the EASD published an expert consensus statement on the approach
to management of hyperglycemia in individuals with type 2 diabetes (82). Highlights of this approach are: intervention at
the time of diagnosis with metformin in
combination with lifestyle changes (MNT
and exercise) and continuing timely augmentation of therapy with additional
agents (including early initiation of insulin therapy) as a means of achieving and
maintaining recommended levels of glycemic control (i.e., A1C 7% for most
patients). As A1C targets are not achieved,
treatment intensification is based on the
addition of another agent from a different
class. The overall objective is to achieve
and maintain glycemic control and to
change interventions when therapeutic
goals are not being met.
The algorithm took into account the
evidence for A1C-lowering of the individual interventions, their additive effects,
and their expense. The precise drugs used
and their exact sequence may not be as
important as achieving and maintaining
glycemic targets safely. Medications not
included in the consensus algorithm, owing to less glucose-lowering effectiveness,
limited clinical data, and/or relative expense, still may be appropriate choices in
individual patients to achieve glycemic
goals. Initiation of insulin at time of diagnosis is recommended for individuals presenting with weight loss or other severe
hyperglycemic symptoms or signs.
S21

E. Diabetes self-management
education
Recommendations
People with diabetes should receive diabetes self-management education
(DSME) according to national standards when their diabetes is diagnosed
and as needed thereafter. (B)
Effective self-management and quality
of life are the key outcomes of DSME
and should be measured and monitored as part of care. (C)
DSME should address psychosocial issues, since emotional well-being is associated with positive diabetes
outcomes. (C)
Because DSME can result in costsavings and improved outcomes (B),
DSME should be adequately reimbursed by third-party payors. (E)
DSME is an essential element of diabetes
care (83 88), and national standards for
DSME (89) are based on evidence for its
benefits. Education helps people with diabetes initiate effective self-management
and cope with diabetes when they are first
diagnosed. Ongoing DSME and support
also help people with diabetes maintain
effective self-management throughout a
lifetime of diabetes as they face new challenges and treatment advances become
available. DSME helps patients optimize
metabolic control, prevent and manage
complications, and maximize quality of
life in a cost-effective manner (90).
DSME is the ongoing process of facilitating the knowledge, skill, and ability
necessary for diabetes self-care. This process incorporates the needs, goals, and life
experiences of the person with diabetes.
The overall objectives of DSME are to support informed decision-making, self-care
behaviors, problem-solving, and active
collaboration with the health care team to
improve clinical outcomes, health status,
and quality of life in a cost-effective manner (89).
Current best practice of DSME is a
skills-based approach that focuses on
helping those with diabetes to make informed self-management choices. DSME
has changed from a didactic approach focusing on providing information to more
theoretically based empowerment models
that focus on helping those with diabetes
make informed self-management decisions. Care of diabetes has shifted to an
approach that is more patient centered
and places the person with diabetes and
his or her family at the center of the care
S22
model working in collaboration with

health care professionals. Patientcentered care is respectful of and responsive to individual patient preferences,
needs, and values and ensures that patient
values guide all decision making (91).
Evidence for the benefits of DSME
Multiple studies have found that DSME is
associated with improved diabetes
knowledge and improved self-care behavior (83), improved clinical outcomes such
as lower A1C (84,85,87,88,92), lower
self-reported weight (83), improved quality of life (86,93), healthy coping (94),
and lower costs (95). Better outcomes
were reported for DSME interventions
that were longer and included follow-up
support (83,96 99), that were culturally
(100,101) and age appropriate (102,103)
and tailored to individual needs and preferences, and that addressed psychosocial
issues and incorporated behavioral strategies (83,87,104 106). Both individual
and group approaches have been found
effective (107110). There is growing evidence for the role of community health
workers and peer (111,112) and lay leaders (113) in delivering DSME and support
in addition to the core team (114).
Diabetes education is associated with
increased use of primary and preventive
services and lower use of acute, inpatient
hospital services (95). Patients who participate in diabetes education are more
likely to follow best practice treatment
recommendations, particularly among
the Medicare population, and have lower
Medicare and commercial claim costs
(115).
National standards for DSME
National standards for DSME are designed to define quality DSME and to assist diabetes educators in a variety of
settings to provide evidence-based education (89). The standards, most recently
revised in 2007, are reviewed and updated every 5 years by a task force representing key organizations involved in the
field of diabetes education and care.
Reimbursement for DSME
DSME, when provided by a program that
meets the national standards for DSME and
is recognized by the ADA or other approval
bodies, is reimbursed as partof the Medicare
program as overseen by the Centers for Medicare and Medicaid Services (CMS) (www.
cms.hhs.gov/DiabetesSelfManagement).
DSME is also covered by a growing number
of other health insurance plans.
F. Medical nutrition therapy

General recommendations
Individuals who have prediabetes or diabetes should receive individualized
medical nutrition therapy (MNT) as
needed to achieve treatment goals, preferably provided by a registered dietitian
familiar with the components of diabetes MNT. (A)
Because MNT can result in cost-savings
and improved outcomes (B), MNT
should be adequately covered by insurance and other payors. (E)
Energy balance, overweight, and
obesity
In overweight and obese insulinresistant individuals, modest weight
loss has been shown to reduce insulin
resistance. Thus, weight loss is recommended for all overweight or obese individuals who have or are at risk for
diabetes. (A)
For weight loss, either low-carbohydrate,
low-fat calorie-restricted, or Mediterranean diets may be effective in the shortterm (up to 2 years). (A)
For patients on low-carbohydrate diets,
monitor lipid profiles, renal function,
and protein intake (in those with nephropathy), and adjust hypoglycemic
therapy as needed. (E)
Physical activity and behavior modification are important components of
weight loss programs and are most
helpful in maintenance of weight loss.
(B)
Recommendations for primary

prevention of diabetes
Among individuals at high risk for developing type 2 diabetes, structured
programs that emphasize lifestyle
changes that include moderate weight
loss (7% body weight) and regular
physical activity (150 min/week),
with dietary strategies including reduced calories and reduced intake of
dietary fat, can reduce the risk for developing diabetes and are therefore
recommended. (A)
Individuals at high risk for type 2 diabetes should be encouraged to achieve
the U.S. Department of Agriculture
(USDA) recommendation for dietary fiber (14 g fiber/1,000 kcal) and foods
containing whole grains (one-half of
grain intake). (B)
Position Statement
Recommendations for management
of diabetes
Macronutrients in diabetes
management
The best mix of carbohydrate, protein,
and fat may be adjusted to meet the
metabolic goals and individual preferences of the person with diabetes. (E)
Monitoring carbohydrate, whether by
carbohydrate counting, choices, or experience-based estimation, remains a
key strategy in achieving glycemic control. (A)
For individuals with diabetes, the use of
the glycemic index and glycemic load
may provide a modest additional benefit for glycemic control over that observed when total carbohydrate is
considered alone. (B)
Saturated fat intake should be 7% of
total calories. (A)
Reducing intake of trans fat lowers LDL
cholesterol and increases HDL cholesterol (A), therefore intake of trans fat
should be minimized. (E)
Other nutrition recommendations
If adults with diabetes choose to use
alcohol, daily intake should be limited
to a moderate amount (one drink per
day or less for adult women and two
drinks per day or less for adult men).
(E)
Routine supplementation with antioxidants, such as vitamins E and C and
carotene, is not advised because of lack
of evidence of efficacy and concern related to long-term safety. (A)
Individualized meal planning should
include optimization of food choices to
meet recommended dietary allowance
(RDA)/dietary reference intake (DRI)
for all micronutrients. (E)
MNT is an integral component of diabetes

prevention, management, and selfmanagement education. In addition to its
role in preventing and controlling diabetes, ADA recognizes the importance of
nutrition as an essential component of an
overall healthy lifestyle. A full review of
the evidence regarding nutrition in preventing and controlling diabetes and its
complications and additional nutritionrelated recommendations can be found in
the ADA position statement, Nutrition
Recommendations and Interventions for
Diabetes, published in 2007 and updated for 2008 (116). Achieving nutrition-related goals requires a coordinated
team effort that includes the active incare.diabetesjournals.org
volvement of the person with prediabetes

or diabetes. Because of the complexity of
nutrition issues, it is recommended that a
registered dietitian who is knowledgeable
and skilled in implementing nutrition
therapy into diabetes management and
education be the team member who provides MNT.
Clinical trials/outcome studies of
MNT have reported decreases in A1C at
3 6 months ranging from 0.25% to 2.9%
with higher reductions seen in type 2 diabetes of shorter duration. Multiple studies have demonstrated sustained
improvements in A1C at 12 months and
longer when an Registered Dietitian provided follow-up visits ranging from
monthly to three sessions per year (117
124). Studies in nondiabetic people suggest that MNT reduces LDL cholesterol by
1525 mg/dl up to 16% (125) and support a role for lifestyle modification in
treating hypertension (125,126).
Because of the effects of obesity on
insulin resistance, weight loss is an important therapeutic objective for overweight or obese individuals with
prediabetes or diabetes (127). Short-term
studies have demonstrated that moderate
weight loss (5% of body weight) in subjects with type 2 diabetes is associated
with decreased insulin resistance, improved measures of glycemia and lipemia,
and reduced blood pressure (128); longer-term studies (52 weeks) showed mixed
effects on A1C in adults with type 2 diabetes (129 131), and in some studies results were confounded by pharmacologic
weight loss therapy. A systematic review
of 80 weight loss studies of 1 year in
duration demonstrated that moderate
weight loss achieved through diet alone,
diet and exercise, and meal replacements
can be achieved and maintained (4.8 8%
weight loss at 12 months) (132). The multifactorial intensive lifestyle intervention
employed in the DPP, which included reduced intake of fat and calories, led to
weight loss averaging 7% at 6 months and
maintenance of 5% weight loss at 3 years,
associated with a 58% reduction in incidence of type 2 diabetes (13). A recent
randomized controlled trial looking at
high-risk individuals in Spain showed the
Mediterranean dietary pattern reduced
the incidence of diabetes in the absence of
weight loss by 52% compared to the lowfat control group (133). Look AHEAD
(Action for Health in Diabetes) is a large
clinical trial designed to determine
whether long-term weight loss will improve glycemia and prevent cardiovascu-
lar events in subjects with type 2 diabetes.

One-year results of the intensive lifestyle
intervention in this trial show an average
8.6% weight loss, significant reduction of
A1C, and reduction in several CVD risk
factors (134), with benefits sustained at 4
years (135). When completed, the Look
AHEAD study should provide insight into
the effects of long-term weight loss on important clinical outcomes.
The optimal macronutrient distribution of weight loss diets has not been established. Although low-fat diets have
traditionally been promoted for weight
loss, several randomized controlled trials
found that subjects on low-carbohydrate
diets (130 g/day of carbohydrate) lost
more weight at 6 months than subjects on
low-fat diets (136,137); however, at 1
year, the difference in weight loss between the low-carbohydrate and low-fat
diets was not significant, and weight loss
was modest with both diets. A study comparing low-fat to low-carbohydrate diets,
both combined with a comprehensive
lifestyle program, showed the same
amount of weight loss (7%) at 2 years in
both groups (138). Another study of overweight women randomized to one of four
diets showed significantly more weight
loss at 12 months with the Atkins lowcarbohydrate diet than with highercarbohydrate diets (139). Changes in
serum triglyceride and HDL cholesterol
were more favorable with the lowcarbohydrate diets. In one study, those
subjects with type 2 diabetes demonstrated a greater decrease in A1C with a
low-carbohydrate diet than with a low-fat
diet (137). A recent meta-analysis showed
that at 6 months, low-carbohydrate diets
were associated with greater improvements in triglyceride and HDL cholesterol
concentrations than low-fat diets; however, LDL cholesterol was significantly
higher on the low-carbohydrate diets
(140). In a 2-year dietary intervention
study, Mediterranean and low-carbohydrate diets were found to be effective and
safe alternatives to a low-fat diet for
weight reduction in moderately obese
participants (141).
The RDA for digestible carbohydrate
is 130 g/day and is based on providing
adequate glucose as the required fuel for
the central nervous system without reliance on glucose production from ingested
protein or fat. Although brain fuel needs
can be met on lower-carbohydrate diets,
long term metabolic effects of very-lowcarbohydrate diets are unclear, and such
diets eliminate many foods that are im-
S23

portant sources of energy, fiber, vitamins,
and minerals and are important in dietary
palatability (142).
Although numerous studies have attempted to identify the optimal mix of
macronutrients for meal plans of people
with diabetes, it is unlikely that one such
combination of macronutrients exists.
The best mix of carbohydrate, protein,
and fat appears to vary depending on individual circumstances. It must be clearly
recognized that regardless of the macronutrient mix, total caloric intake must be appropriate to weight management goal.
Further, individualization of the macronutrient composition will depend on the metabolic status of the patient (e.g., lipid
profile, renal function) and/or food preferences. Plant-based diets (vegan or vegetarian) that are well planned and nutritionally
adequate have also been shown to improve
metabolic control (143,144).
The primary goal with respect to dietary fat in individuals with diabetes is to
limit saturated fatty acids, trans fatty acids,
and cholesterol intake so as to reduce risk
for CVD. Saturated and trans fatty acids are
the principal dietary determinants of
plasma LDL cholesterol. There is a lack of
evidence on the effects of specific fatty acids
on people with diabetes, so the recommended goals are consistent with those for
individuals with CVD (125,145).
Reimbursement for MNT
MNT, when delivered by a registered dietitian
according to nutrition practice guidelines, is
reimbursedaspartoftheMedicareprogramas
overseen by the Centers for Medicare and
MedicaidServices(CMS)(www.cms.hhs.gov/
medicalnutritiontherapy).
G. Physical activity
Recommendations
People with diabetes should be advised
to perform at least 150 min/week of
moderate-intensity aerobic physical activity (50 70% of maximum heart
rate). (A)
In the absence of contraindications,
people with type 2 diabetes should be
encouraged to perform resistance training three times per week. (A)
Exercise is an important part of the diabetes management plan. Regular exercise

has been shown to improve blood glucose
control, reduce cardiovascular risk factors, contribute to weight loss, and improve well-being. Furthermore, regular
exercise may prevent type 2 diabetes in
S24
high-risk individuals (1315). Structured

exercise interventions of at least 8 weeks
duration have been shown to lower A1C
by an average of 0.66% in people with
type 2 diabetes, even with no significant
change in BMI (146). Higher levels of exercise intensity are associated with greater
improvements in A1C and in fitness
(147). A new joint position statement of
the American Diabetes Association and
the American College of Sports Medicine
summarizes the evidence for the benefits
of exercise in people with type 2 diabetes
(148).
Frequency and type of exercise
The U.S. Department of Health and Human Services Physical Activity Guidelines for Americans (149) suggest that
adults over age 18 years do 150 min/week
of moderate-intensity, or 75 min/week of
vigorous aerobic physical activity, or an
equivalent combination of the two. In addition, the guidelines suggest that adults
also do muscle-strengthening activities
that involve all major muscle groups two
or more days per week. The guidelines
suggest that adults over age 65 years, or
those with disabilities, follow the adult
guidelines if possible or (if this is not possible) be as physically active as they are
able. Studies included in the metaanalysis of effects of exercise interventions
on glycemic control (146) had a mean
number of sessions per week of 3.4, with
a mean of 49 min/session. The DPP lifestyle intervention, which included 150
min/week of moderate intensity exercise,
had a beneficial effect on glycemia in
those with prediabetes. Therefore, it
seems reasonable to recommend that people with diabetes try to follow the physical
activity guidelines for the general population.
Progressive resistance exercise improves insulin sensitivity in older men
with type 2 diabetes to the same or even a
greater extent as aerobic exercise (150).
Clinical trials have provided strong evidence for the A1C-lowering value of resistance training in older adults with type
2 diabetes (151,152) and for an additive
benefit of combined aerobic and resistance exercise in adults with type 2 diabetes (153).
Evaluation of the diabetic patient
before recommending an exercise
program
Prior guidelines suggested that before recommending a program of physical activity, the provider should assess patients
with multiple cardiovascular risk factors

for coronary artery disease (CAD). As discussed more fully in VI.A.5. Coronary
heart disease screening and treatment, the
area of screening asymptomatic diabetic
patients for CAD remains unclear, and a
recent ADA consensus statement on this
issue concluded that routine screening is
not recommended (154). Providers
should use clinical judgment in this area.
Certainly, high risk patients should be encouraged to start with short periods of
low intensity exercise and increase the intensity and duration slowly.
Providers should assess patients for
conditions that might contraindicate certain types of exercise or predispose to injury, such as uncontrolled hypertension,
severe autonomic neuropathy, severe peripheral neuropathy or history of foot
lesions, and unstable proliferative retinopathy. The patients age and previous
physical activity level should be considered.
Exercise in the presence of
nonoptimal glycemic control
Hyperglycemia. When people with type
1 diabetes are deprived of insulin for
12 48 h and are ketotic, exercise can
worsen hyperglycemia and ketosis (155);
therefore, vigorous activity should be
avoided in the presence of ketosis. However, it is not necessary to postpone exercise based simply on hyperglycemia,
provided the patient feels well and urine
and/or blood ketones are negative.
Hypoglycemia. In individuals taking insulin and/or insulin secretagogues, physical activity can cause hypoglycemia if
medication dose or carbohydrate consumption is not altered. For individuals
on these therapies, added carbohydrate
should be ingested if pre-exercise glucose
levels are 100 mg/dl (5.6 mmol/l). Hypoglycemia is rare in diabetic individuals
who are not treated with insulin or insulin
secretagogues, and no preventive measures for hypoglycemia are usually advised in these cases.
Exercise in the presence of specific
long-term complications of diabetes
Retinopathy. In the presence of proliferative diabetic retinopathy (PDR) or severe
nonproliferative diabetic retinopathy
(NPDR), vigorous aerobic or resistance
exercise may be contraindicated because
of the risk of triggering vitreous hemorrhage or retinal detachment (156).
Peripheral neuropathy. Decreased pain
sensation in the extremities results in incare.diabetesjournals.org
Position Statement
creased risk of skin breakdown and infection and of Charcot joint destruction.
Prior recommendations have advised
nonweight-bearing exercise for patients
with severe peripheral neuropathy. However, studies have shown that moderateintensity walking may not lead to
increased risk of foot ulcers or reulceration in those with peripheral neuropathy (157). All individuals with
peripheral neuropathy should wear
proper footwear and examine their feet
daily to detect lesions early. Anyone with
a foot injury or open sore should be restricted to nonweight-bearing activities.
Autonomic neuropathy. Autonomic neuropathy can increase the risk of exerciseinduced injury or adverse event through
decreased cardiac responsiveness to exercise, postural hypotension, impaired
thermoregulation, impaired night vision
due to impaired papillary reaction, and
unpredictable carbohydrate delivery from
gastroparesis predisposing to hypoglycemia (158). Autonomic neuropathy is also
strongly associated with CVD in people
with diabetes (159,160). People with diabetic autonomic neuropathy should undergo cardiac investigation before
beginning physical activity more intense
than that to which they are accustomed.
Albuminuria and nephropathy. Physical
activity can acutely increase urinary protein excretion. However, there is no evidence that vigorous exercise increases the
rate of progression of diabetic kidney disease, and there is likely no need for any
specific exercise restrictions for people
with diabetic kidney disease (161).
H. Psychosocial assessment and care
Recommendations
Assessment of psychological and social
situation should be included as an ongoing part of the medical management
of diabetes. (E)
Psychosocial screening and follow-up
should include, but is not limited to,
attitudes about the illness, expectations
for medical management and outcomes, affect/mood, general and diabetes-related quality of life, resources
(financial, social, and emotional), and
psychiatric history. (E)
Screen for psychosocial problems such
as depression and diabetes-related distress, anxiety, eating disorders, and
cognitive impairment when selfmanagement is poor. (C)
Psychological and social problems can

impair the individuals (162165) or familys ability to carry out diabetes care tasks
and therefore compromise health status.
There are opportunities for the clinician
to assess psychosocial status in a timely
and efficient manner so that referral for
appropriate services can be accomplished.
Key opportunities for screening of
psychosocial status occur at diagnosis,
during regularly scheduled management
visits, during hospitalizations, at discovery of complications, or when problems
with glucose control, quality of life, or adherence are identified. Patients are likely
to exhibit psychological vulnerability at
diagnosis and when their medical status
changes, e.g., the end of the honeymoon
period, when the need for intensified
treatment is evident, and when complications are discovered (164).
Issues known to impact selfmanagement and health outcomes include but are not limited to: attitudes
about the illness, expectations for medical
management and outcomes, affect/mood,
general and diabetes-related quality of
life, diabetes-related distress (166), resources (financial, social, and emotional)
(167), and psychiatric history (168
170). Screening tools are available for a
number of these areas (105). Indications
for referral to a mental health specialist
familiar with diabetes management may
include: gross noncompliance with medical regimen (by self or others) (170), depression with the possibility of self-harm,
debilitating anxiety (alone or with depression), indications of an eating disorder
(171), or cognitive functioning that
significantly impairs judgment. It is
preferable to incorporate psychological
assessment and treatment into routine
care rather than waiting for identification
of a specific problem or deterioration in
psychological status (105). Although the
clinician may not feel qualified to treat
psychological problems, utilizing the patient-provider relationship as a foundation for further treatment can increase the
likelihood that the patient will accept referral for other services. It is important to
establish that emotional well-being is part
of diabetes management.
I. When treatment goals are not met
For a variety of reasons, some people with
diabetes and their health care providers
do not achieve the desired goals of treatment (Table 10). Re-thinking the treatment regimen may require assessment of
barriers including income, health literacy,

diabetes distress, depression, and competing demands, including those related
to family responsibilities and dynamics.
Other strategies may include culturally
appropriate and enhanced DSME, comanagement with a diabetes team, referral to a medical social worker for
assistance with insurance coverage, or
change in pharmacological therapy. Initiation of or increase in SMBG, utilization
of CGM, frequent contact with the patient, or referral to a mental health professional or physician with special expertise
in diabetes may be useful. Providing patients with an algorithm for self-titration
of insulin doses based on SMBG results
may be helpful for type 2 patients who
take insulin (172).
J. Hypoglycemia
Recommendations
Glucose (1520 g) is the preferred
treatment for the conscious individual
with hypoglycemia, although any form
of carbohydrate that contains glucose
may be used. If SMBG 15 min after
treatment shows continued hypoglycemia, the treatment should be repeated.
Once SMBG glucose returns to normal,
the individual should consume a meal
or snack to prevent recurrence of hypoglycemia. (E)
Glucagon should be prescribed for all
individuals at significant risk of severe
hypoglycemia, and caregivers or family
members of these individuals should be
instructed in its administration. Glucagon administration is not limited to
health care professionals. (E)
Individuals with hypoglycemia unawareness or one or more episodes of
severe hypoglycemia should be advised
to raise their glycemic targets to strictly
avoid further hypoglycemia for at least
several weeks, to partially reverse hypoglycemia unawareness and reduce risk
of future episodes. (B)
Hypoglycemia is the leading limiting factor in the glycemic management of type 1

and insulin-treated type 2 diabetes (173).
Mild hypoglycemia may be inconvenient
or frightening to patients with diabetes,
and more severe hypoglycemia can cause
acute harm to the person with diabetes or
others, if it causes falls, motor vehicle accidents, or other injury. A large cohort
study suggested that among older adults
with type 2 diabetes, a history of severe
hypoglycemia was associated with greater
S25

risk of dementia (174). Conversely, evidence from the DCCT/EDIC trial, which
involved younger type 1 patients, suggested no association of frequency of severe hypoglycemia with cognitive decline
(175). Treatment of hypoglycemia
(plasma glucose 70 mg/dl) requires ingestion of glucose- or carbohydratecontaining foods. The acute glycemic
response correlates better with the glucose content than with the carbohydrate
content of the food. Although pure glucose is the preferred treatment, any form
of carbohydrate that contains glucose will
raise blood glucose. Added fat may retard
and then prolong the acute glycemic response. Ongoing activity of insulin or insulin secretagogues may lead to
recurrence of hypoglycemia unless further food is ingested after recovery.
Severe hypoglycemia (where the individual requires the assistance of another
person and cannot be treated with oral
carbohydrate due to confusion or unconsciousness) should be treated using emergency glucagon kits, which require a
prescription. Those in close contact with,
or having custodial care of, people with
hypoglycemia-prone diabetes (family
members, roommates, school personnel,
child care providers, correctional institution staff, or coworkers), should be instructed in use of such kits. An individual
does not need to be a health care professional to safely administer glucagon. Care
should be taken to ensure that unexpired
glucagon kits are available.
Prevention of hypoglycemia is a critical component of diabetes management.
Teaching people with diabetes to balance
insulin use, carbohydrate intake, and exercise is a necessary but not always sufficient strategy. In type 1 diabetes and
severely insulin-deficient type 2 diabetes,
the syndrome of hypoglycemia unawareness, or hypoglycemia-associated autonomic failure, can severely compromise
stringent diabetes control and quality of
life. The deficient counterregulatory hormone release and autonomic responses in
this syndrome are both risk factors for,
and caused by, hypoglycemia. A corollary
to this vicious cycle is that several weeks
of avoidance of hypoglycemia has been
demonstrated to improve counterregulation and awareness to some extent in
many patients (176). Hence, patients with
one or more episodes of severe hypoglycemia may benefit from at least shortterm relaxation of glycemic targets.
S26
K. Intercurrent illness
The stress of illness, trauma, and/or surgery frequently aggravates glycemic control and may precipitate diabetic
ketoacidosis (DKA) or nonketotic hyperosmolar state, life-threatening conditions
that require immediate medical care to
prevent complications and death. Any
condition leading to deterioration in glycemic control necessitates more frequent
monitoring of blood glucose and (in ketosis-prone patients) urine or blood ketones. Marked hyperglycemia requires
temporary adjustment of the treatment
program and, if accompanied by ketosis,
vomiting, or alteration in level of consciousness, immediate interaction with
the diabetes care team. The patient treated
with noninsulin therapies or MNT alone
may temporarily require insulin. Adequate fluid and caloric intake must be assured. Infection or dehydration are more
likely to necessitate hospitalization of the
person with diabetes than the person
without diabetes.
The hospitalized patient should be
treated by a physician with expertise in
the management of diabetes. For further
information on management of patients
with hyperglycemia in the hospital, see
VIII.A. Diabetes care in the hospital. For
further information on management of
DKA or nonketotic hyperosmolar state,
refer to the ADA consensus statement on
hyperglycemic crises (172).
L. Bariatric surgery
Recommendations
Bariatric surgery may be considered for
adults with BMI 35 kg/m2 and type 2
diabetes, especially if the diabetes or associated comorbidities are difficult to
control with lifestyle and pharmacologic therapy. (B)
Patients with type 2 diabetes who have
undergone bariatric surgery need lifelong lifestyle support and medical
monitoring. (E)
Although small trials have shown glycemic benefit of bariatric surgery in patients with type 2 diabetes and BMI of
30 35 kg/m2, there is currently insufficient evidence to generally recommend surgery in patients with BMI 35
kg/m2 outside of a research protocol.
(E)
T h e l o n g - t e r m b e n e fi t s , c o s t effectiveness, and risks of bariatric surgery in individuals with type 2 diabetes
should be studied in well-designed
controlled trials with optimal medical
and lifestyle therapy as the comparator.

(E)
Gastric reduction surgery, either gastric
banding or procedures that involve bypassing, transposing, or resecting sections
of the small intestine, when part of a comprehensive team approach, can be an effective weight loss treatment for severe
obesity, and national guidelines support
its consideration for people with type 2
diabetes who have BMI exceeding 35 kg/
m2. Bariatric surgery has been shown to
lead to near- or complete normalization of
glycemia in 5595% of patients with
type 2 diabetes, depending on the surgical
procedure. A meta-analysis of studies of
bariatric surgery involving 3,188 patients
with diabetes reported that 78% had remission of diabetes (normalization of
blood glucose levels in the absence of
medications), and that the remission rates
were sustained in studies that had follow-up exceeding 2 years (177). Remission rates tend to be lower with
procedures that only constrict the stomach, and higher with those that bypass
portions of the small intestine. Additionally, there is a suggestion that intestinal
bypass procedures may have glycemic effects that are independent of their effects
on weight, perhaps involving the incretin
axis.
One randomized controlled trial
compared adjustable gastric banding to
best available medical and lifestyle therapy in subjects with type 2 diabetes diagnosed less than 2 years before
randomization and BMI 30 40 kg/m2
(178). In this trial, 73% of surgically
treated patients achieved remission of
their diabetes, compared with 13% of
those treated medically. The latter group
lost only 1.7% of body weight, suggesting
that their therapy was not optimal. Overall the trial had 60 subjects, and only 13
had a BMI under 35 kg/m2, making it difficult to generalize these results widely to
diabetic patients who are less severely
obese or with longer duration of diabetes.
In a more recent study involving 110 patients with type 2 diabetes and a mean
BMI of 47 kg/m2, Roux-en-Y gastric bypass resulted in a mean loss of excess
weight of 63% at 1 year and 84% at 2
years (179).
Bariatric surgery is costly in the short
term and has some risks. Rates of morbidity and mortality directly related to the
surgery have been reduced considerably
in recent years, with 30-day mortality
rates now 0.28%, similar to those of lapacare.diabetesjournals.org
Position Statement
roscopic cholecystectomy (180). Longerterm concerns include vitamin and
mineral deficiencies, osteoporosis, and
rare but often severe hypoglycemia from
insulin hypersecretion. Cohort studies attempting to match subjects suggest that
the procedure may reduce longer-term
mortality rates (181), and it is reasonable
to postulate that there may be recouping
of costs over the long run. Recent retrospective analyses and modeling studies
suggest that these procedures may be cost
effective, when one considers reduction
in subsequent health care costs (182
184). However, studies of the mechanisms of glycemic improvement and
long-term benefits and risks of bariatric
surgery in individuals with type 2 diabetes, especially those who are not severely
obese, will require well-designed clinical
trials, with optimal medical and lifestyle
therapy of diabetes and cardiovascular
risk factors as the comparator.
M. Immunization
Recommendations
Annually provide an influenza vaccine
to all diabetic patients at least 6 months
of age. (C)
Administer pneumococcal polysaccharide vaccine to all diabetic patients 2
years of age. A one-time revaccination is
recommended for individuals 64
years of age previously immunized
when they were 65 years of age if the
vaccine was administered 5 years
ago. Other indications for repeat vaccination include nephrotic syndrome,
chronic renal disease, and other immunocompromised states, such as after
transplantation. (C)
Influenza and pneumonia are common,
preventable infectious diseases associated
with high mortality and morbidity in the
elderly and in people with chronic diseases. Though there are limited studies
reporting the morbidity and mortality of
influenza and pneumococcal pneumonia
specifically in people with diabetes, observational studies of patients with a variety of chronic illnesses, including
diabetes, show that these conditions are
associated with an increase in hospitalizations for influenza and its complications.
People with diabetes may be at increased
risk of the bacteremic form of pneumococcal infection and have been reported
to have a high risk of nosocomial bacteremia, which has a mortality rate as high as
50% (185).
Safe and effective vaccines are available that can greatly reduce the risk of
serious complications from these diseases
(186,187). In a case-control series, influenza vaccine was shown to reduce diabetes-related hospital admission by as much
as 79% during flu epidemics (186). There
is sufficient evidence to support that people with diabetes have appropriate serologic and clinical responses to these
vaccinations. The Centers for Disease
Control and Prevention (CDC) Advisory
Committee on Immunization Practices
recommends influenza and pneumococcal vaccines for all individuals with diabetes (http://www.cdc.gov/vaccines/recs/).
VI. PREVENTION AND
MANAGEMENT OF
DIABETES COMPLICATIONS
A. CVD
CVD is the major cause of morbidity and
mortality for individuals with diabetes,
and the largest contributor to the direct
and indirect costs of diabetes. The common conditions coexisting with type 2
diabetes (e.g., hypertension and dyslipidemia) are clear risk factors for CVD, and
diabetes itself confers independent risk.
Numerous studies have shown the efficacy of controlling individual cardiovascular risk factors in preventing or slowing
CVD in people with diabetes. Large benefits are seen when multiple risk factors
are addressed globally (188,189). Risk for
coronary heart disease (CHD) and for
CVD in general can be estimated using
multivariable risk factor approaches, and
such a strategy may be desirable to undertake in adult patients prior to instituting
preventive therapy.
1. Hypertension/blood pressure
control
Recommendations
Screening and diagnosis
Blood pressure should be measured at
every routine diabetes visit. Patients
found to have systolic blood pressure
130 mmHg or diastolic blood pressure 80 mmHg should have blood
pressure confirmed on a separate day.
Repeat systolic blood pressure 130
mmHg or diastolic blood pressure 80
mmHg confirms a diagnosis of hypertension. (C)
Goals
A goal systolic blood pressure 130
mmHg is appropriate for most patients
with diabetes. (C)
Based on patient characteristics and response to therapy, higher or lower systolic blood pressure targets may be
appropriate. (B)
Patients with diabetes should be treated
to a diastolic blood pressure 80
mmHg. (B)
Treatment
Patients with a systolic blood pressure
of 130 139 mmHg or a diastolic blood
pressure of 80 89 mmHg may be given
lifestyle therapy alone for a maximum
of 3 months and then, if targets are not
achieved, be treated with addition of
pharmacological agents. (E)
Patients with more severe hypertension
(systolic blood pressure 140 or diastolic blood pressure 90 mmHg) at
diagnosis or follow-up should receive
pharmacologic therapy in addition to
lifestyle therapy. (A)
Lifestyle therapy for hypertension consists of: weight loss, if overweight; Dietary Approaches to Stop Hypertension
(DASH)-style dietary pattern including
reducing sodium and increasing potassium intake; moderation of alcohol intake; and increased physical activity.
(B)
Pharmacologic therapy for patients
with diabetes and hypertension should
be with a regimen that includes either
an ACE inhibitor or an ARB. If one class
is not tolerated, the other should be
substituted. If needed to achieve blood
pressure targets, a thiazide diuretic
should be added to those with an estimated GFR (eGFR) (see below) 30
ml/min/1.73 m2 and a loop diuretic for
those with an eGFR 30 ml/min/1.73
m2. (C)
Multiple drug therapy (two or more
agents at maximal doses) is generally
required to achieve blood pressure targets. (B)
If ACE inhibitors, ARBs, or diuretics are
used, kidney function and serum potassium levels should be monitored. (E)
In pregnant patients with diabetes and
chronic hypertension, blood pressure
target goals of 110 129/6579 mmHg
are suggested in the interest of longterm maternal health and minimizing
impaired fetal growth. ACE inhibitors
and ARBs are contraindicated during
pregnancy. (E)
S27

Hypertension is a common comorbidity
of diabetes, affecting the majority of patients, with prevalence depending on type
of diabetes, age, obesity, and ethnicity.
Hypertension is a major risk factor for
both CVD and microvascular complications. In type 1 diabetes, hypertension is
often the result of underlying nephropathy, while in type 2 diabetes it usually
coexists with other cardiometabolic risk
factors.
Screening and diagnosis
Measurement of blood pressure in the office should be done by a trained individual and should follow the guidelines
established for nondiabetic individuals:
measurement in the seated position, with
feet on the floor and arm supported at
heart level, after 5 min of rest. Cuff size
should be appropriate for the upper arm
circumference. Elevated values should be
confirmed on a separate day. Because of
the clear synergistic risks of hypertension
and diabetes, the diagnostic cut-off for a
diagnosis of hypertension is lower in people with diabetes (blood pressure 130/
80) than those without diabetes (blood
pressure 140/90 mmHg) (190).
Home blood pressure self-monitoring
and 24-h ambulatory blood pressure
monitoring may provide additional evidence of white coat and masked hypertension and other discrepancies between
office and true blood pressure, and in
studies in nondiabetic populations, home
measurements may better correlate with
CVD risk than office measurements
(191,192). However, the preponderance
of the clear evidence of benefits of treatment of hypertension in people with diabetes is based on office measurements.
Treatment goals
Epidemiologic analyses show that blood
pressure values 115/75 mmHg are associated with increased cardiovascular
event rates and mortality in individuals
with diabetes (190,193,194). Randomized clinical trials have demonstrated the
benefit (reduction in CHD events, stroke,
and nephropathy) of lowering blood
pressure to 140 mmHg systolic and
80 mmHg diastolic in individuals with
diabetes (190,195197). The ACCORD
trial examined whether lowering blood
pressure to a systolic 120 mmHg provides greater cardiovascular protection
than a systolic blood pressure level of
130 140 mmHg in patients with type 2
diabetes at high risk for CVD (198). The
blood pressure achieved was 119/64
S28
mmHg in the intensive group and 133/70

mmHg in the standard group; the difference achieved was attained with an average of 3.4 medications per participant in
the intensive group and 2.1 in the standard therapy group. The primary outcome was a composite of nonfatal MI,
nonfatal stroke, and CVD death; the hazard ratio for the primary end point in the
intensive group was 0.88 (95% CI 0.73
1.06; P 0.20). Of the prespecified secondary end points, only stroke and
nonfatal stroke were statistically significantly reduced by intensive blood pressure treatment, with a hazard ratio of 0.59
(95% CI 0.39 0.89, P 0.01) and 0.63
(95% CI 0.41 0.96, P 0.03), respectively. If this finding is real, the number
needed to treat to prevent one stroke over
the course of 5 years with intensive blood
pressure management is 89.
In predefined subgroup analyses,
there was a suggestion of heterogeneity
(P 0.08) based on whether participants
were randomized to standard or intensive
glycemia intervention. In those randomized to standard glycemic control, the
event rate for the primary end point was
1.89 per year in the intensive blood pressure arm and 2.47 in the standard blood
pressure arm, while the respective rates in
the intensive glycemia arm were 1.85 and
1.73. If this observation is true, it suggests
that intensive management to a systolic
blood pressure target of 120 mmHg
may be of benefit in those who are not
targeting an A1C of 6% and/or that the
benefit of intensive blood pressure management is diminished by more intensive
glycemia management targeting an A1C
of 6%.
Other recent randomized trial data
include those from ADVANCE, in which
treatment with an angiotensin-converting
enzyme inhibitor and a thiazide-type diuretic reduced the rate of death but not
the composite macrovascular outcome.
However, the ADVANCE trial had no
specified targets for the randomized comparison, and the mean systolic blood
pressure in the intensive group (135
mmHg) was not as low as the mean systolic blood pressure in the ACCORD standard therapy group (199). A post hoc
analysis of blood pressure control in
6,400 patients with diabetes and CAD
enrolled in the International VerapamilTrandolapril (INVEST) trial demonstrated
that tight control (130 mmHg) was
not associated with improved CV outcomes compared with usual care (130
140 mmHg) (200).
Only the ACCORD blood pressure

trial formally has examined treatment targets 130 mmHg in diabetes. It is possible that lowering systolic blood pressure
from the low-130s to less than 120 mmHg
does not further reduce coronary events
or death, and that most of the benefit from
lowering blood pressure is achieved by
targeting a goal of 140 mmHg. However, this has not been formally assessed.
The absence of significant harm, the
trends toward benefit in stroke, and the
potential heterogeneity with respect to intensive glycemia management suggests
that previously recommended targets are
reasonable pending further analyses and
results. Systolic blood pressure targets
more or less stringent than 130 mmHg
may be appropriate for individual patients, based on response to therapy,
medication tolerance, and individual
characteristics, keeping in mind that most
analyses have suggested that outcomes
are worse if the systolic blood pressure is
140 mmHg.
Treatment strategies
Although there are no well-controlled
studies of diet and exercise in the treatment of hypertension in individuals with
diabetes, the Dietary Approaches to
Stop Hypertension (DASH) study in
nondiabetic individuals has shown antihypertensive effects similar to pharmacologic monotherapy. Lifestyle therapy
consists of reducing sodium intake (to
1,500 mg/day) and excess body weight;
increasing consumption of fruits, vegetables (8 10 servings/day), and low-fat
dairy products (23 servings/day); avoiding excessive alcohol consumption (no
more than 2 servings/day in men and no
more than 1 serving/day in women)
(201); and increasing activity levels
(190). These nonpharmacological strategies may also positively affect glycemia
and lipid control. Their effects on cardiovascular events have not been established.
An initial trial of nonpharmacologic therapy may be reasonable in diabetic individuals with mild hypertension (systolic
blood pressure 130 139 mmHg or diastolic blood pressure 80 89 mmHg). If
systolic blood pressure is 140 mmHg
and/or diastolic is 90 mmHg at the time
of diagnosis, pharmacologic therapy
should be initiated along with nonpharmacologic therapy (190).
Lowering of blood pressure with regimens based on a variety of antihypertensive drugs, including ACE inhibitors,
ARBs, -blockers, diuretics, and calcium
Position Statement
channel blockers, has been shown to be
effective in reducing cardiovascular
events. Several studies suggested that
ACE inhibitors may be superior to dihydropyridine calcium channel blockers in
reducing cardiovascular events (202
204). However, a variety of other studies
have shown no specific advantage to ACE
inhibitors as initial treatment of hypertension in the general hypertensive population, but rather an advantage on
cardiovascular outcomes of initial therapy
with low-dose thiazide diuretics
(190,205,206).
In people with diabetes, inhibitors of
the renin-angiotensin system (RAS) may
have unique advantages for initial or early
therapy of hypertension. In a nonhypertension trial of high-risk individuals, including a large subset with diabetes, an
ACE inhibitor reduced CVD outcomes
(207). In patients with congestive heart
failure (CHF), including diabetic subgroups, ARBs have been shown to reduce
major CVD outcomes (208 211), and in
type 2 patients with significant nephropathy, ARBs were superior to calcium
channel blockers for reducing heart failure (212). Though evidence for distinct
advantages of RAS inhibitors on CVD outcomes in diabetes remains conflicting
(195,206), the high CVD risks associated
with diabetes, and the high prevalence of
undiagnosed CVD, may still favor recommendations for their use as first-line hypertension therapy in people with
diabetes (190). Recently, the blood pressure arm of the ADVANCE trial demonstrated that routine administration of a
fixed combination of the ACE inhibitor
perindopril and the diuretic indapamide
significantly reduced combined microvascular and macrovascular outcomes, as
well as CVD and total mortality. The improved outcomes could also have been
due to lower achieved blood pressure in
the perindopril-indapamide arm (199).
In addition, the Avoiding Cardiovascular
Events through Combination Therapy in
Patients Living with Systolic Hypertension (ACCOMPLISH) trial showed a decrease in morbidity and mortality in those
receiving benazapril and amlodipine versus benazapril and hydrochlorothiazide.
The compelling benefits of RAS inhibitors
in diabetic patients with albuminuria or
renal insufficiency provide additional rationale for use of these agents (see VI.B.
Nephropathy screening and treatment).
An important caveat is that most patients with hypertension require multidrug therapy to reach treatment goals,
especially diabetic patients whose targets

are lower. Many patients will require
three or more drugs to reach target goals
(190). If blood pressure is refractory to
optimal doses of at least three antihypertensive agents of different classifications,
one of which should be a diuretic, clinicians should consider an evaluation for
secondary forms of hypertension.
During pregnancy in diabetic women
with chronic hypertension, target blood
pressure goals of systolic blood pressure
110 129 mmHg and diastolic blood
pressure 6579 mmHg are reasonable, as
they contribute to long-term maternal
health. Lower blood pressure levels may
be associated with impaired fetal growth.
During pregnancy, treatment with ACE
inhibitors and ARBs is contraindicated,
since they can cause fetal damage. Antihypertensive drugs known to be effective
and safe in pregnancy include methyldopa, labetalol, diltiazem, clonidine, and
prazosin. Chronic diuretic use during
pregnancy has been associated with restricted maternal plasma volume, which
might reduce uteroplacental perfusion
(213).
2. Dyslipidemia/lipid management
Recommendations
Screening
In most adult patients, measure fasting
lipid profile at least annually. In adults
with low-risk lipid values (LDL cholesterol 100 mg/dl, HDL cholesterol
50 mg/dl, and triglycerides 150
mg/dl), lipid assessments may be repeated every 2 years. (E)
Treatment recommendations and

goals
Lifestyle modification focusing on the
reduction of saturated fat, trans fat, and
cholesterol intake; increase of omega-3
fatty acids, viscous fiber, and plant
stanols/sterols; weight loss (if indicated); and increased physical activity
should be recommended to improve
the lipid profile in patients with diabetes. (A)
Statin therapy should be added to lifestyle therapy, regardless of baseline
lipid levels, for diabetic patients:
with overt CVD. (A)
without CVD who are over age 40
years and have one or more other
CVD risk factors. (A)
For patients at lower risk than above
(e.g., without overt CVD and under age
40 years), statin therapy should be considered in addition to lifestyle therapy if

LDL cholesterol remains above 100
mg/dl or in those with multiple CVD
risk factors. (E)
In individuals without overt CVD, the
primary goal is an LDL cholesterol
100 mg/dl (2.6 mmol/l). (A)
In individuals with overt CVD, a lower
LDL cholesterol goal of 70 mg/dl (1.8
mmol/l), using a high dose of a statin, is
an option. (B)
If drug-treated patients do not reach the
above targets on maximal tolerated statin therapy, a reduction in LDL cholesterol of 30 40% from baseline is an
alternative therapeutic goal. (A)
Triglyceride levels 150 mg/dl (1.7
mmol/l) and HDL cholesterol 40
mg/dl (1.0 mmol/l) in men and 50
mg/dl (1.3 mmol/l) in women, are desirable. However, LDL cholesterol
targeted statin therapy remains the
preferred strategy. (C)
If targets are not reached on maximally
tolerated doses of statins, combination
therapy using statins and other lipidlowering agents may be considered to
achieve lipid targets but has not been
evaluated in outcome studies for either
CVD outcomes or safety. (E)
Statin therapy is contraindicated in
pregnancy. (E)
Evidence for benefits of lipidlowering therapy

Patients with type 2 diabetes have an increased prevalence of lipid abnormalities,
contributing to their high risk of CVD.
For the past decade or more, multiple
clinical trials demonstrated significant effects of pharmacologic (primarily statin)
therapy on CVD outcomes in subjects
with CHD and for primary CVD prevention (214). Sub-analyses of diabetic subgroups of larger trials (215219) and
trials specifically in subjects with diabetes
(220,221) showed significant primary
and secondary prevention of CVD
events CHD deaths in diabetic populations. As shown in Table 11, and similar
to findings in nondiabetic subjects, reduction in hard CVD outcomes (CHD
death and nonfatal MI) can be more
clearly seen in diabetic subjects with high
baseline CVD risk (known CVD and/or
very high LDL cholesterol levels), but
overall the benefits of statin therapy in
people with diabetes at moderate or high
risk for CVD are convincing.
Low levels of HDL cholesterol, often
associated with elevated triglyceride lev-
S29

Table 11Reduction in 10-year risk of major CVD endpoints (CHD death/non-fatal MI) in major statin trials, or substudies of major trials,
in diabetic subjects (n 16,032)
Study (ref.)
CVD
4S-DM (215)
ASPEN 2 (220)
HPS-DM (216)
CARE-DM (217)
TNT-DM (218)
HPS-DM (216)
CARDS (221)
ASPEN 1 (220)
ASCOT-DM (219)
Statin dose and

comparator
Risk
reduction (%)
Relative risk
reduction (%)
Absolute risk
reduction (%)
LDL cholesterol
reduction (mg/dl)
LDL cholesterol
reduction (%)
Simvastatin 2040 mg
vs. placebo
Atorvastatin 10 mg vs.
placebo
Simvastatin 40 mg vs.
placebo
Pravastatin 40 mg vs.
placebo
10 mg
Simvastatin 40 mg vs.
placebo
placebo
placebo
placebo
85.7 to 43.2
50
42.5
186 to 119
36
39.5 to 24.5
34
15
112 to 79
29
43.8 to 36.3
17
7.5
123 to 84
31
40.8 to 35.4
13
5.4
136 to 99
27
26.3 to 21.6
18
4.7
99 to 77
22
17.5 to 11.5
34
6.0
124 to 86
31
11.5 to 7.5
35
118 to 71
40
9.8 to 7.9
19
1.9
114 to 80
30
11.1 to 10.2
0.9
125 to 82
34
Studies were of differing lengths (3.35.4 years) and used somewhat different outcomes, but all reported rates of CVD death and nonfatal MI. In this tabulation,
results of the statin on 10-year risk of major CVD endpoints (CHD death/nonfatal MI) are listed for comparison between studies. Correlation between 10-year CVD
risk of the control group and the absolute risk reduction with statin therapy is highly significant (P 0.0007). Analyses provided by Craig Williams, PharmD, Oregon
Health & Science University, 2007.
els, are the most prevalent pattern of dyslipidemia in persons with type 2 diabetes.
However, the evidence base for drugs that
target these lipid fractions is significantly
less robust than that for statin therapy
(222). Nicotinic acid has been shown to
reduce CVD outcomes (223), although
the study was done in a nondiabetic cohort. Gemfibrozil has been shown to decrease rates of CVD events in subjects
without diabetes (224,225) and in the diabetic subgroup in one of the larger trials
(224). However, in a large trial specific to
diabetic patients, fenofibrate failed to reduce overall cardiovascular outcomes
(226).
Dyslipidemia treatment and target
lipid levels
For most patients with diabetes, the first
priority of dyslipidemia therapy (unless
severe hypertriglyceridemia is the immediate issue) is to lower LDL cholesterol to
a target goal of 100 mg/dl (2.60 mmol/l)
(227). Lifestyle intervention, including
MNT, increased physical activity, weight
loss, and smoking cessation, may allow
some patients to reach lipid goals. Nutrition intervention should be tailored according to each patients age, type of
diabetes, pharmacological treatment,
lipid levels, and other medical conditions
and should focus on the reduction of satS30
urated fat, cholesterol, and trans unsaturated fat intake and increases in omega-3
fatty acids, viscous fiber (such as in oats,
legumes, citrus), and plant stanols/
sterols. Glycemic control can also beneficially modify plasma lipid levels,
particularly in patients with very high
triglycerides and poor glycemic control.
In those with clinical CVD or over age
40 years with other CVD risk factors,
pharmacological treatment should be
added to lifestyle therapy regardless of
baseline lipid levels. Statins are the drugs
of choice for LDL cholesterol lowering.
In patients other than those described
above, statin treatment should be considered if there is an inadequate LDL cholesterol response to lifestyle modifications
and improved glucose control, or if the
patient has increased cardiovascular risk
(e.g., multiple cardiovascular risk factors
or long duration of diabetes). Very little
clinical trial evidence exists for type 2 diabetic patients under age 40 years or for
type 1 patients of any age. In the Heart
Protection Study (lower age limit 40
years), the subgroup of 600 patients with
type 1 diabetes had a proportionately similar reduction in risk as patients with type
2 diabetes, although not statistically significant (216). Although the data are not
definitive, consideration should be given
to similar lipid-lowering goals in type 1
diabetic patients as in type 2 diabetic patients, particularly if they have other cardiovascular risk factors.
Alternative LDL cholesterol goals
Virtually all trials of statins and CVD outcomes tested specific doses of statins
against placebo, other doses of statin, or
other statins, rather than aiming for specific LDL cholesterol goals (228). As can
be seen in Table 11, placebo-controlled
trials generally achieved LDL cholesterol
reductions of 30 40% from baseline.
Hence, LDL cholesterol lowering of this
magnitude is an acceptable outcome for
patients who cannot reach LDL cholesterol goals due to severe baseline elevations in LDL cholesterol and/or
intolerance of maximal, or any, statin
doses. Additionally for those with baseline LDL cholesterol minimally above 100
mg/dl, prescribing statin therapy to lower
LDL cholesterol about 30 40% from
baseline is probably more effective than
prescribing just enough to get LDL cholesterol slightly below 100 mg/dl.
Recent clinical trials in high-risk patients, such as those with acute coronary
syndromes or previous cardiovascular
events (229 231), have demonstrated
that more aggressive therapy with high
doses of statins to achieve an LDL cholesterol of 70 mg/dl led to a significant recare.diabetesjournals.org
Position Statement
duction in further events. Therefore, a
reduction in LDL cholesterol to a goal of
70 mg/dl is an option in very-high-risk
diabetic patients with overt CVD (232).
In individual patients, LDL cholesterol lowering with statins is highly variable, and this variable response is poorly
understood (233). Reduction of CVD
events with statins correlates very closely
with LDL cholesterol lowering (214).
When maximally tolerated doses of statins fail to significantly lower LDL cholesterol (30% reduction from patients
baseline), the primary aim of combination
therapy should be to achieve additional
LDL cholesterol lowering. Niacin, fenofibrate, ezetimibe, and bile acid sequestrants all offer additional LDL cholesterol
lowering. The evidence that combination
therapy provides a significant increment
in CVD risk reduction over statin therapy
alone is still elusive.
In 2008, a consensus panel convened
by the American Diabetes Association and
the American College of Cardiology recommended a greater focus on non-HDL
cholesterol and apo lipoprotein B (apo B)
in patients who are likely to have small
LDL particles, such as people with diabetes (234). The consensus panel suggested
that for statin-treated patients in whom
the LDL cholesterol goal would be 70
mg/dl (non-HDL cholesterol 100 mg/
dl), apo B should be measured and treated
to 80 mg/dl. For patients on statins with
an LDL cholesterol goal of 100 mg/dl
(non-HDL cholesterol 130 mg/dl), apo
B should be measured and treated to 90
mg/dl.
triglyceride levels are accompanied by

only modest changes in glucose that are
generally amenable to adjustment of diabetes therapy (235,236).
Treatment of other lipoprotein

fractions or targets
Severe hypertriglyceridemia may warrant
immediate therapy of this abnormality
with lifestyle and usually pharmacologic
therapy (fibric acid derivative, niacin, or
fish oil) to reduce the risk of acute pancreatitis. In the absence of severe hypertriglyceridemia, therapy targeting HDL
cholesterol or triglycerides has intuitive
appeal but lacks the evidence base of statin therapy. If the HDL cholesterol is 40
mg/dl and the LDL cholesterol between
100 and 129 mg/dl, gemfibrozil or niacin
might be used, especially if a patient is
intolerant to statins. Niacin is the most
effective drug for raising HDL cholesterol.
It can significantly increase blood glucose
at high doses, but recent studies demonstrate that at modest doses (750 2,000
mg/day), significant improvements in
LDL cholesterol, HDL cholesterol, and
3. Antiplatelet agents
Combination therapy
Combination therapy, with a statin and a
fibrate or statin and niacin, may be efficacious for treatment for all three lipid fractions, but this combination is associated
with an increased risk for abnormal
transaminase levels, myositis, or rhabdomyolysis. The risk of rhabdomyolysis is
higher with higher doses of statins and
with renal insufficiency and seems to be
lower when statins are combined with fenofibrate than gemfibrozil (237). In the
recent ACCORD study, the combination
of fenofibrate and simvastatin did not reduce the rate of fatal cardiovascular
events, nonfatal myocardial infarction, or
nonfatal stroke, as compared with simvastatin alone, in patients with type 2 diabetes who were at high risk for CVD.
However, prespecified subgroup analyses
suggested heterogeneity in treatment effects according to sex, with a benefit for
men and possible harm for women, and a
possible benefit of combination therapy
for patients with both triglyceride level
204 mg/dl and HDL cholesterol level
34 mg/dl (238). Other ongoing trials
may provide much-needed evidence for
the effects of combination therapy on cardiovascular outcomes.
Table 12 summarizes common treatment
goals for A1C, blood pressure, and HDL
cholesterol.
Recommendations
Consider aspirin therapy (75162 mg/
day) as a primary prevention strategy in
those with type 1 or type 2 diabetes at
increased cardiovascular risk (10-year
risk 10%). This includes most men
50 years of age or women 60 years
of age who have at least one additional
major risk factor (family history of
CVD, hypertension, smoking, dyslipidemia, or albuminuria). (C)
Aspirin should not be recommended
for CVD prevention for adults with diabetes at low CVD risk (10-year CVD
risk 5%, such as in men 50 and
women 60 years of age with no major
additional CVD risk factors), since the
potential adverse effects from bleeding
likely offset the potential benefits. (C)
In patients in these age-groups with
Table 12Summary of recommendations

for glycemic blood pressure and lipid control
for most adults with diabetes
A1C
Blood pressure
Lipids
LDL cholesterol
7.0%*
130/80 mmHg
100 mg/dl
(2.6 mmol/l)
*More or less stringent glycemic goals may be appropriate for individual patients. Goals should be
individualized based on: duration of diabetes, age/
life expectancy, comorbid conditions, known CVD
or advanced microvascular complications, hypoglycemia unawareness, and individual patient considerations. Based on patient characteristics and
response to therapy, higher or lower systolic blood
pressure targets may be appropriate. In individuals
with overt CVD, a lower LDL cholesterol goal of
70 mg/dl (1.8 mmol/l), using a high dose of a
statin, is an option.
multiple other risk factors (e.g., 10-year

risk 510%), clinical judgment is required. (E)
Use aspirin therapy (75162 mg/day)
as a secondary prevention strategy in
those with diabetes with a history of
CVD. (A)
For patients with CVD and documented aspirin allergy, clopidogrel (75
mg/day) should be used. (B)
Combination therapy with ASA (75
162 mg/day) and clopidogrel (75 mg/
day) is reasonable for up to a year after
an acute coronary syndrome. (B)
ADA and the American Heart Association

(AHA) have, in the past, jointly recommended that low-dose aspirin therapy be
used as a primary prevention strategy in
those with diabetes at increased cardiovascular risk, including those who are
over 40 years of age or those with additional risk factors (family history of CVD,
hypertension, smoking, dyslipidemia, or
albuminuria) (188). These recommendations were derived from several older trials that included small numbers of
patients with diabetes.
Aspirin has been shown to be effective in reducing cardiovascular morbidity
and mortality in high-risk patients with
previous myocardial infarction or stroke
(secondary prevention). Its net benefit in
primary prevention among patients with
no previous cardiovascular events is more
controversial, both for patients with and
without a history of diabetes (239). Two
recent randomized controlled trials of aspirin specifically in patients with diabetes
failed to show a significant reduction in
CVD end points, raising further questions
about the efficacy of aspirin for primary
S31

prevention in people with diabetes
(240,241).
The Anti-thrombotic Trialists (ATT)
collaborators recently published an individual patient-level meta-analysis of the
six large trials of aspirin for primary prevention in the general population. These
trials collectively enrolled over 95,000
participants, including almost 4,000 with
diabetes. Overall, they found that aspirin
reduced the risk of vascular events by
12% (RR 0.88 [95% CI 0.82 0.94]). The
largest reduction was for nonfatal myocardial infarction with little effect on CHD
death (RR 0.95 [95% CI 0.78 1.15]) or
total stroke. There was some evidence of a
difference in aspirin effect by sex. Aspirin
significantly reduced CHD events in men
but not in women. Conversely, aspirin
had no effect on stroke in men but significantly reduced stroke in women. Notably, sex differences in aspirins effects
have not been observed in studies of secondary prevention (239). In the six trials
examined by the ATT collaborators, the
effects of aspirin on major vascular events
were similar for patients with or without
diabetes: RR 0.88 (95% CI 0.671.15)
and 0.87 (0.79 0.96), respectively. The
CI was wider for those with diabetes because of their smaller number.
Based on the currently available evidence, aspirin appears to have a modest
effect on ischemic vascular events with
the absolute decrease in events depending
on the underlying CVD risk. The main
adverse effects appear to be an increased
risk of gastrointestinal bleeding. The excess risk may be as high as 15 per 1,000
per year in real-world settings. In adults
with CVD risk greater than 1% per year,
the number of CVD events prevented will
be similar to or greater than the number of
episodes of bleeding induced, although
these complications do not have equal effects on long-term health (242).
In 2010, a position statement of the
ADA, AHA, and American College of Cardiology Foundation (ACCF) updated
prior joint recommendations for primary
prevention (243). Low dose (75162 mg/
day) aspirin use for primary prevention is
reasonable for adults with diabetes and no
previous history of vascular disease who
are at increased CVD risk (10-year risk of
CVD events over 10%) and who are not at
increased risk for bleeding. This generally
includes most men over age 50 years and
women over age 60 years who also have
one or more of the following major risk
factors: smoking, hypertension, dyslipiS32
demia, family history of premature CVD,

and albuminuria.
However, aspirin is no longer recommended for those at low CVD risk
(women under age 60 years and men under age 50 years with no major CVD risk
factors; 10-year CVD risk under 5%) as
the low benefit is likely to be outweighed
by the risks of significant bleeding. Clinical judgment should be used for those at
intermediate risk (younger patients with
one or more risk factors, or older patients
with no risk factors; those with 10-year
CVD risk of 510%) until further research
is available. Use of aspirin in patients under the age of 21 years is contraindicated
due to the associated risk of Reyes syndrome.
Average daily dosages used in most
clinical trials involving patients with diabetes ranged from 50 to 650 mg but were
mostly in the range of 100 to 325 mg/day.
There is little evidence to support any specific dose, but using the lowest possible
dosage may help reduce side effects
(244). Although platelets from patients
with diabetes have altered function, it is
unclear what, if any, impact that finding
has on the required dose of aspirin for
cardioprotective effects in the patient
with diabetes. Many alternate pathways
for platelet activation exist that are independent of thromboxane A2 and thus not
sensitive to the effects of aspirin (245).
Therefore, while aspirin resistance appears higher in the diabetic patients when
measured by a variety of ex vivo and in
vitro methods (platelet aggrenometry,
measurement of thromboxane B2), these
observations alone are insufficient to empirically recommend higher doses of aspirin be used in the diabetic patient at this
time.
Clopidogrel has been demonstrated
to reduce CVD events in diabetic individuals (246). It is recommended as adjunctive therapy in the first year after an acute
coronary syndrome or as alternative therapy in aspirin-intolerant patients.
4. Smoking cessation
Recommendations
Advise all patients not to smoke. (A)
Include smoking cessation counseling
and other forms of treatment as a routine component of diabetes care. (B)
A large body of evidence from epidemiological, case-control, and cohort studies

provides convincing documentation of
the causal link between cigarette smoking
and health risks. Much of the work documenting the impact of smoking on
health did not separately discuss results
on subsets of individuals with diabetes,
but suggests that the identified risks are at
least equivalent to those found in the general population. Other studies of individuals with diabetes consistently
demonstrate that smokers have a heightened risk of CVD, premature death, and
increased rate of microvascular complications of diabetes. Smoking may have a
role in the development of type 2 diabetes.
The routine and thorough assessment of tobacco use is important as a
means of preventing smoking or encouraging cessation. A number of large
randomized clinical trials have demonstrated the efficacy and cost-effectiveness of brief counseling in smoking
cessation, including the use of quit
lines, in the reduction of tobacco use.
For the patient motivated to quit, the
addition of pharmacological therapy to
counseling is more effective than either
treatment alone. Special considerations
should include assessment of level of
nicotine dependence, which is associated with difficulty in quitting and relapse (247).
5. CHD screening and treatment
Recommendations
Screening
In asymptomatic patients, routine
screening for CAD is not recommended, as it does not improve outcomes as long as CVD risk factors are
treated. (A)
Treatment
In patients with known CVD, ACE inhibitor (C) and aspirin and statin therapy (A) (if not contraindicated) should
be used to reduce the risk of cardiovascular events.
In patients with a prior myocardial infarction, -blockers should be continued for at least 2 years after the event
(B).
Longer term use of -blockers in the
absence of hypertension is reasonable if
well tolerated, but data are lacking. (E)
Avoid TZD treatment in patients with
symptomatic heart failure. (C)
Metformin may be used in patients with
stable CHF if renal function is normal.
It should be avoided in unstable or hospitalized patients with CHF. (C)
Position Statement
Screening for CAD is reviewed in a recently updated consensus statement
(154). To identify the presence of CAD
in diabetic patients without clear or
suggestive symptoms, a risk factor
based approach to the initial diagnostic
evaluation and subsequent follow-up
has intuitive appeal. However, recent
studies concluded that using this approach fails to identify which patients
with type 2 diabetes will have silent
ischemia on screening tests (159,248).
Candidates for cardiac testing include those with 1) typical or atypical
cardiac symptoms and 2) an abnormal
resting ECG. The screening of asymptomatic patients remains controversial,
especially as intensive medical therapy,
indicated in diabetic patients at high
risk for CVD, has an increasing evidence
base for providing equal outcomes to
invasive revascularization, including in
diabetic patients (249,250). There is
also some evidence that silent myocardial ischemia may reverse over time,
adding to the controversy concerning
aggressive screening strategies (251).
Finally, a recent randomized observational trial demonstrated no clinical
benefit to routine screening of asymptomatic patients with type 2 diabetes
and normal ECGs (252). Despite abnormal myocardial perfusion imaging in
more than one in five patients, cardiac
outcomes were essentially equal (and
very low) in screened versus unscreened patients. Accordingly, the
overall effectiveness, especially the
cost-effectiveness, of such an indiscriminate screening strategy is now questioned.
Newer noninvasive CAD screening
methods, such as computed tomography (CT) and CT angiography have
gained in popularity. These tests infer
the presence of coronary atherosclerosis
by measuring the amount of calcium in
coronary arteries and, in some circumstances, by direct visualization of luminal stenoses. Although asymptomatic
diabetic patients found to have a higher
coronary disease burden have more future cardiac events (253255), the role
of these tests beyond risk stratification
is not clear. Their routine use leads to
radiation exposure and may result in
unnecessary invasive testing such as
coronary angiography and revascularization procedures. The ultimate balance of benefit, cost, and risks of such
an approach in asymptomatic patients
remains controversial, particularly in
the modern setting of aggressive CVD

risk factor control.
In all patients with diabetes, cardiovascular risk factors should be assessed
at least annually. These risk factors include dyslipidemia, hypertension,
smoking, a positive family history of
premature coronary disease, and the
presence of micro- or macroalbuminuria. Abnormal risk factors should be
treated as described elsewhere in these
guidelines. Patients at increased CHD
risk should receive aspirin and a statin
and ACE inhibitor or ARB therapy if hypertensive, unless there are contraindications to a particular drug class. While
clear benefit exists for ACE inhibitor
and ARB therapy in patients with nephropathy or hypertension, the benefits
in patients with CVD in the absence of
these conditions is less clear, especially
when LDL cholesterol is concomitantly
controlled (256,257).
B. Nephropathy screening and
treatment
Recommendations
To reduce the risk or slow the progression of nephropathy, optimize glucose
control. (A)
To reduce the risk or slow the progression of nephropathy, optimize blood
pressure control. (A)
Screening
Perform an annual test to assess urine
albumin excretion in type 1 diabetic patients with diabetes duration of 5 years
and in all type 2 diabetic patients starting at diagnosis. (E)
Measure serum creatinine at least annually in all adults with diabetes regardless of the degree of urine albumin
excretion. The serum creatinine should
be used to estimate GFR and stage the
level of chronic kidney disease (CKD),
if present. (E)
Treatment
In the treatment of the nonpregnant patient with micro- or macroalbuminuria,
either ACE inhibitors or ARBs should
be used. (A)
While there are no adequate head-tohead comparisons of ACE inhibitors
and ARBs, there is clinical trial support
for each of the following statements:
In patients with type 1 diabetes, with
hypertension and any degree of albu
minuria, ACE inhibitors have been

shown to delay the progression of nephropathy. (A)
In patients with type 2 diabetes, hypertension, and microalbuminuria,
both ACE inhibitors and ARBs have
been shown to delay the progression
to macroalbuminuria. (A)
In patients with type 2 diabetes, hypertension, macroalbuminuria, and
renal insufficiency (serum creatinine
1.5 mg/dl), ARBs have been shown
to delay the progression of nephropathy. (A)
If one class is not tolerated, the other
should be substituted. (E)
Reduction of protein intake to 0.8 1.0
g kg body wt1 day1 in individuals
with diabetes and the earlier stages of
CKD and to 0.8 g kg body wt1
day1 in the later stages of CKD may
improve measures of renal function
(urine albumin excretion rate, GFR)
and is recommended. (B)
When ACE inhibitors, ARBs, or diuretics are used, monitor serum creatinine
and potassium levels for the development of acute kidney disease and hyperkalemia. (E)
Continued monitoring of urine albumin excretion to assess both response
to therapy and progression of disease is
recommended. (E)
When eGFR 60 ml/min/1.73 m2,
evaluate and manage potential complications of CKD. (E)
Consider referral to a physician experienced in the care of kidney disease
when there is uncertainty about the etiology of kidney disease (heavy proteinuria, active urine sediment, absence of
retinopathy, rapid decline in GFR), difficult management issues, or advanced
kidney disease. (B)
Diabetic nephropathy occurs in 20 40%

of patients with diabetes and is the single
leading cause of end-stage renal disease
(ESRD). Persistent albuminuria in the
range of 30 299 mg/24 h (microalbuminuria) has been shown to be the earliest
stage of diabetic nephropathy in type 1
diabetes and a marker for development of
nephropathy in type 2 diabetes. Microalbuminuria is also a well-established
marker of increased CVD risk (258,259).
Patients with microalbuminuria who
progress to macroalbuminuria (300
mg/24 h) are likely to progress to ESRD
(260,261). However, a number of interventions have been demonstrated to re-
S33

duce the risk and slow the progression of
renal disease.
Intensive diabetes management with
the goal of achieving near-normoglycemia has been shown in large prospective
randomized studies to delay the onset of
microalbuminuria and the progression of
micro- to macroalbuminuria in patients
with type 1 (262,263) and type 2 (55,56)
diabetes. The UKPDS provided strong evidence that control of blood pressure can
reduce the development of nephropathy
(195). In addition, large prospective randomized studies in patients with type 1
diabetes have demonstrated that achievement of lower levels of systolic blood
pressure (140 mmHg) resulting from
treatment using ACE inhibitors provides a
selective benefit over other antihypertensive drug classes in delaying the progression from micro- to macroalbuminuria
and can slow the decline in GFR in patients with macroalbuminuria (264
266). In type 2 diabetes with
hypertension and normoalbuminuria,
RAS inhibition has been demonstrated to
delay onset of microalbuminuria (267).
In addition, ACE inhibitors have been
shown to reduce major CVD outcomes
(i.e., myocardial infarction, stroke, death)
in patients with diabetes (207), thus further supporting the use of these agents in
patients with microalbuminuria, a CVD
risk factor. ARBs do not prevent microalbuminuria in normotensive patients
with type 1 or type 2 diabetes (268,269);
however, ARBs have been shown to reduce the rate of progression from microto macroalbuminuria as well as ESRD in
patients with type 2 diabetes (270 272).
Some evidence suggests that ARBs have a
smaller magnitude of rise in potassium
compared with ACE inhibitors in people
with nephropathy (273,274). Combinations of drugs that block the reninangiotensin-aldosterone system (e.g., an
ACE inhibitor plus an ARB, a mineralocorticoid antagonist, or a direct renin inhibitor) have been shown to provide
additional lowering of albuminuria (275
278). However, the long-term effects of
such combinations on renal or cardiovascular outcomes have not yet been evaluated in clinical trials, and they are
associated with increased risk for hyperkalemia.
Other drugs, such as diuretics, calcium channel blockers, and -blockers
should be used as additional therapy to
further lower blood pressure in patients
already treated with ACE inhibitors or
ARBs (212), or as alternate therapy in the
S34
Table 13Definitions of abnormalities in albumin excretion

Spot collection
(g/mg
creatinine)
Category
Normal
Microalbuminuria
Macro (clinical)-albuminuria
30
30299
300
rare individual unable to tolerate ACE inhibitors or ARBs.

Studies in patients with varying stages
of nephropathy have shown that protein
restriction of dietary protein helps slow
the progression of albuminuria, GFR decline, and occurrence of ESRD (279
282). Dietary protein restriction should
be considered particularly in patients
whose nephropathy seems to be progressing despite optimal glucose and blood
pressure control and use of ACE inhibitor
and/or ARBs (282).
Assessment of albuminuria status
and renal function
Screening for microalbuminuria can be
performed by measurement of the albumin-to-creatinine ratio in a random spot
collection; 24-h or timed collections are
more burdensome and add little to prediction or accuracy (283,284). Measurement of a spot urine for albumin only,
whether by immunoassay or by using a
dipstick test specific for microalbumin,
without simultaneously measuring urine
creatinine, is somewhat less expensive but
susceptible to false-negative and -positive
determinations as a result of variation in
urine concentration due to hydration and
other factors.
Abnormalities of albumin excretion
are defined in Table 13. Because of variability in urinary albumin excretion, two
of three specimens collected within a 3- to
6-month period should be abnormal before considering a patient to have crossed
one of these diagnostic thresholds. Exercise within 24 h, infection, fever, CHF,

marked hyperglycemia, and marked hypertension may elevate urinary albumin
excretion over baseline values.
Information on presence of abnormal
urine albumin excretion in addition to
level of GFR may be used to stage CKD.
The National Kidney Foundation classification (Table 14) is primarily based on
GFR levels and therefore differs from
other systems, in which staging is based
primarily on urinary albumin excretion
(285). Studies have found decreased GFR
in the absence of increased urine albumin
excretion in a substantial percentage of
adults with diabetes (286). Serum creatinine should therefore be measured at least
annually in all adults with diabetes, regardless of the degree of urine albumin
excretion.
Serum creatinine should be used to
estimate GFR and to stage the level of
CKD, if present. eGFR is commonly coreported by laboratories or can be estimated using formulae such as the
Modification of Diet in Renal Disease
(MDRD) study equation (287). Recent reports have indicated that the MDRD is
more accurate for the diagnosis and stratification of CKD in patients with diabetes
than the Cockcroft-Gault formula (288).
GFR calculators are available at http://
www.nkdep.nih.gov.
The role of continued annual quantitative assessment of albumin excretion
after diagnosis of microalbuminuria and
institution of ACE inhibitor or ARB
therapy and blood pressure control is
unclear. Continued surveillance can assess both response to therapy and progression of disease. Some suggest that
reducing abnormal albuminuria (30
mg/g) to the normal or near-normal
range may improve renal and cardiovascular prognosis, but this approach has
not been formally evaluated in prospective trials.
Table 14Stages of CKD
Stage
1
2
3
4
5
Description
GFR (ml/min per 1.73 m2

body surface area)
Kidney damage* with normal or increased GFR

Kidney damage* with mildly decreased GFR
Moderately decreased GFR
Severely decreased GFR
Kidney failure
90
6089
3059
1529
15 or dialysis
*Kidney damage defined as abnormalities on pathologic, urine, blood, or imaging tests. Adapted from ref.
284.
Position Statement
Complications of kidney disease correlate with level of kidney function. When
the eGFR is less than 60 ml/min/1.73 m2,
screening for complications of CKD is indicated (Table 15). Early vaccination
against hepatitis B is indicated in patients
likely to progress to end-stage kidney disease.
Consider referral to a physician experienced in the care of kidney disease
when there is uncertainty about the etiology of kidney disease (heavy proteinuria, active urine sediment, absence of
retinopathy, rapid decline in GFR, resistant hypertension), difficult management issues, or advanced kidney
disease. The threshold for referral may
vary depending on the frequency with
which a provider encounters diabetic
patients with significant kidney disease.
Consultation with a nephrologist when
stage 4 CKD develops has been found to
reduce cost, improve quality of care,
and keep people off dialysis longer
(289). However, nonrenal specialists
should not delay educating their patients about the progressive nature of
diabetic kidney disease; the renal preservation benefits of aggressive treatment of blood pressure, blood glucose,
and hyperlipidemia; and the potential
need for renal replacement therapy.
Table 15Management of CKD in diabetes

GFR (ml/min/
1.73 m2)
All patients
4560
3044
30
Recommendations
Screening
Adults and children aged 10 years or
older with type 1 diabetes should have
an initial dilated and comprehensive
eye examination by an ophthalmologist
or optometrist within 5 years after the
onset of diabetes. (B)
Patients with type 2 diabetes should
have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist shortly after the
diagnosis of diabetes. (B)
Subsequent examinations for type 1
and type 2 diabetic patients should be
repeated annually by an ophthalmologist or optometrist. Less frequent exams
Yearly measurement of creatinine, urinary albumin excretion, potassium

Referral to nephrology if possibility for nondiabetic kidney disease exists
(duration type 1 diabetes 10 years, heavy proteinuria, abnormal
findings on renal ultrasound, resistant hypertension, rapid fall in
GFR, or active urinary sediment)
Consider need for dose adjustment of medications
Monitor eGFR every 6 months
Monitor electrolytes, bicarbonate, hemoglobin, calcium, phosphorus,
parathyroid hormone at least yearly
Assure vitamin D sufficiency
Consider bone density testing
Referral for dietary counselling
Monitor eGFR every 3 months
Monitor electrolytes, bicarbonate, calcium, phosphorus, parathyroid
hormone, hemoglobin, albumin, weight every 36 months
Consider need for dose adjustment of medications
Referral to nephrologist
Adapted from http://www.kidney.org/professionals/KDOQI/guideline_diabetes/.
C. Retinopathy screening and

treatment
To reduce the risk or slow the progression of retinopathy, optimize glycemic
control. (A)
To reduce the risk or slow the progression of retinopathy, optimize blood
pressure control. (A)
Recommended
(every 23 years) may be considered

following one or more normal eye exams. Examinations will be required
more frequently if retinopathy is progressing. (B)
High-quality fundus photographs can
detect most clinically significant diabetic retinopathy. Interpretation of the
images should be performed by a
trained eye care provider. While retinal
photography may serve as a screening
tool for retinopathy, it is not a substitute for a comprehensive eye exam,
which should be performed at least initially and at intervals thereafter as recommended by an eye care professional.
(E)
Women with preexisting diabetes who
are planning a pregnancy or who have
become pregnant should have a comprehensive eye examination and should
be counseled on the risk of development and/or progression of diabetic retinopathy. Eye examination should
occur in the first trimester with close
follow-up throughout pregnancy and
for 1 year postpartum. (B)
Treatment
Promptly refer patients with any level of
macular edema, severe NPDR, or any
PDR to an ophthalmologist who is
knowledgeable and experienced in the
management and treatment of diabetic
retinopathy. (A)
Laser photocoagulation therapy is indicated to reduce the risk of vision loss in
patients with high-risk PDR, clinically

significant macular edema, and in some
cases of severe NPDR. (A)
The presence of retinopathy is not a
contraindication to aspirin therapy for
cardioprotection, as this therapy does
not increase the risk of retinal hemorrhage. (A)
Diabetic retinopathy is a highly specific

vascular complication of both type 1 and
type 2 diabetes, with prevalence strongly
related to the duration of diabetes. Diabetic retinopathy is the most frequent
cause of new cases of blindness among
adults aged 20 74 years. Glaucoma, cataracts, and other disorders of the eye occur earlier and more frequently in people
with diabetes.
In addition to duration of diabetes,
other factors that increase the risk of, or
are associated with, retinopathy include
chronic hyperglycemia (290), the presence of nephropathy (291), and hypertension (292). Intensive diabetes
management with the goal of achieving
near normoglycemia has been shown in
large prospective randomized studies to
prevent and/or delay the onset and progression of diabetic retinopathy (47,55,
56,64). Lowering blood pressure has
been shown to decrease the progression
of retinopathy (195). Several case series
and a controlled prospective study suggest that pregnancy in type 1 diabetic patients may aggravate retinopathy
S35

(293,294); laser photocoagulation surgery can minimize this risk (294).
One of the main motivations for
screening for diabetic retinopathy is the
established efficacy of laser photocoagulation surgery in preventing vision loss.
Two large trials, the Diabetic Retinopathy
Study (DRS) and the Early Treatment Diabetic Retinopathy Study (ETDRS), provide the strongest support for the
therapeutic benefits of photocoagulation
surgery.
The DRS (295) showed that panretinal photocoagulation surgery reduced the
risk of severe vision loss from PDR from
15.9% in untreated eyes to 6.4% in
treated eyes, with greatest risk-to-benefit
ratio in those with baseline disease (disc
neovascularization or vitreous hemorrhage).
The ETDRS (296) established the
benefit of focal laser photocoagulation
surgery in eyes with macular edema, particularly those with clinically significant
macular edema, with reduction of doubling of the visual angle (e.g., 20/50 to
20/100) from 20% in untreated eyes to
8% in treated eyes. The ETDRS also verified the benefits of panretinal photocoagulation for high-risk PDR and in olderonset patients with severe NPDR or lessthan-high-risk PDR.
Laser photocoagulation surgery in
both trials was beneficial in reducing the
risk of further vision loss, but generally
not beneficial in reversing already diminished acuity. This preventive effect and
the fact that patients with PDR or macular
edema may be asymptomatic provide
strong support for a screening program to
detect diabetic retinopathy.
As retinopathy is estimated to take at
least 5 years to develop after the onset of
hyperglycemia, patients with type 1 diabetes should have an initial dilated and
comprehensive eye examination within 5
years after the onset of diabetes. Patients
with type 2 diabetes, who generally have
had years of undiagnosed diabetes and
who have a significant risk of prevalent
DR at time of diabetes diagnosis, should
have an initial dilated and comprehensive
eye examination soon after diagnosis. Examinations should be performed by an
ophthalmologist or optometrist who is
knowledgeable and experienced in diagnosing the presence of diabetic retinopathy and is aware of its management.
Subsequent examinations for type 1 and
type 2 diabetic patients are generally repeated annually. Less-frequent exams
(every 23 years) may be cost effective
S36
after one or more normal eye exams,

while examinations will be required more
frequently if retinopathy is progressing
(297).
The use of retinal photography with
remote reading by experts has great potential in areas where qualified eye care
professionals are not available, and may
also enhance efficiency and reduce costs
when the expertise of ophthalmologists
can be utilized for more complex examinations and for therapy (298). In-person
exams are still necessary when the photos
are unacceptable and for follow-up of abnormalities detected. Photos are not a
substitute for a comprehensive eye exam,
which should be performed at least initially and at intervals thereafter as recommended by an eye care professional.
Results of eye examinations should be
documented and transmitted to the referring health care professional. For a detailed review of the evidence and further
discussion of diabetic retinopathy, see the
ADAs technical review and position statement on this subject (297,300).
D. Neuropathy screening and
treatment (301)
Recommendations
All patients should be screened for distal symmetric polyneuropathy (DPN) at
diagnosis and at least annually thereafter, using simple clinical tests. (B)
Electrophysiological testing is rarely
needed, except in situations where the
clinical features are atypical. (E)
Screening for signs and symptoms of
autonomic neuropathy should be instituted at diagnosis of type 2 diabetes and
5 years after the diagnosis of type 1 diabetes. Special testing is rarely needed
and may not affect management or outcomes. (E)
Medications for the relief of specific
symptoms related to DPN and autonomic neuropathy are recommended,
as they improve the quality of life of the
patient. (E)
The diabetic neuropathies are heterogeneous with diverse clinical manifestations. They may be focal or diffuse. Most
common among the neuropathies are
chronic sensorimotor DPN and autonomic neuropathy. Although DPN is a diagnosis of exclusion, complex
investigations to exclude other conditions
are rarely needed.
The early recognition and appropriate management of neuropathy in the pa-
tient with diabetes is important for a

number of reasons: 1) nondiabetic neuropathies may be present in patients with
diabetes and may be treatable, 2) a number of treatment options exist for symptomatic diabetic neuropathy, 3) up to
50% of DPN may be asymptomatic and
patients are at risk of insensate injury to
their feet, and 4) autonomic neuropathy
and particularly cardiovascular autonomic neuropathy is associated with substantial morbidity and even mortality.
Specific treatment for the underlying
nerve damage is currently not available,
other than improved glycemic control,
which may modestly slow progression
(63) but not reverse neuronal loss. Effective symptomatic treatments are available
for some manifestations of DPN and autonomic neuropathy.
Diagnosis of neuropathy
Distal symmetric polyneuropathy. Patients with diabetes should be screened
annually for DPN using tests such as pinprick sensation, vibration perception
(using a 128-Hz tuning fork), 10-g monofilament pressure sensation at the distal
plantar aspect of both great toes and
metatarsal joints, and assessment of ankle
reflexes. Combinations of more than one
test have 87% sensitivity in detecting
DPN. Loss of 10-g monofilament perception and reduced vibration perception
predict foot ulcers (301). Importantly, in
patients with neuropathy, particularly
when severe, causes other than diabetes
should always be considered, such as
neurotoxic mediations, heavy metal poisoning, alcohol abuse, vitamin B12 deficiency (especially in those taking
metformin for prolonged periods (302),
renal disease, chronic inflammatory demyelinating neuropathy, inherited neuropathies, and vasculitis (303).
Diabetic autonomic neuropathy (304).
The symptoms and signs of autonomic
dysfunction should be elicited carefully
during the history and physical examination. Major clinical manifestations of diabetic autonomic neuropathy include
resting tachycardia, exercise intolerance,
orthostatic hypotension, constipation,
gastroparesis, erectile dysfunction, sudomotor dysfunction, impaired neurovascular function, and, potentially,
autonomic failure in response to hypoglycemia.
Cardiovascular autonomic neuropathy, a CVD risk factor (93), is the most
studied and clinically important form of
diabetic autonomic neuropathy. Cardiocare.diabetesjournals.org
Position Statement
vascular autonomic neuropathy may be
indicated by resting tachycardia (100
bpm) or orthostasis (a fall in systolic
blood pressure 20 mmHg upon standing without an appropriate heart rate response); it is also associated with
increased cardiac event rates.
Gastrointestinal neuropathies (e.g.,
esophageal enteropathy, gastroparesis,
constipation, diarrhea, fecal incontinence) are common, and any section of
the gastrointestinal tract may be affected.
Gastroparesis should be suspected in individuals with erratic glucose control or
with upper gastrointestinal symptoms
without other identified cause. Evaluation of solid-phase gastric emptying using
double-isotope scintigraphy may be done
if symptoms are suggestive, but test results often correlate poorly with symptoms. Constipation is the most common
lower-gastrointestinal symptom but can
alternate with episodes of diarrhea.
Diabetic autonomic neuropathy is
also associated with genitourinary tract
disturbances. In men, diabetic autonomic
neuropathy may cause erectile dysfunction and/or retrograde ejaculation. Evaluation of bladder dysfunction should be
performed for individuals with diabetes
who have recurrent urinary tract infections, pyelonephritis, incontinence, or a
palpable bladder.
Symptomatic treatments
DPN. The first step in management of patients with DPN should be to aim for stable and optimal glycemic control.
Although controlled trial evidence is lacking, several observational studies suggest
that neuropathic symptoms improve not
only with optimization of control, but
also with the avoidance of extreme blood
glucose fluctuations. Patients with painful
DPN may benefit from pharmacological
treatment of their symptoms: many
agents have efficacy confirmed in published randomized controlled trials, several of which are Food and Drug
Administration (FDA)-approved for the
management of painful DPN.
Treatment of autonomic neuropathy
Gastroparesis symptoms may improve
with dietary changes and prokinetic
agents such as metoclopramide or erythromycin. Treatments for erectile dysfunction may include phosphodiesterase type
5 inhibitors, intracorporeal or intraurethral prostaglandins, vacuum devices, or
penile prostheses. Interventions for other
manifestations of autonomic neuropathy
are described in the ADA statement on

neuropathy (301). As with DPN treatments, these interventions do not change
the underlying pathology and natural history of the disease process, but may have a
positive impact on the quality of life of the
patient.
E. Foot care
Recommendations
For all patients with diabetes, perform
an annual comprehensive foot examination to identify risk factors predictive
of ulcers and amputations. The foot examination should include inspection,
assessment of foot pulses, and testing
for loss of protective sensation (10-g
monofilament plus testing any one of:
vibration using 128-Hz tuning fork,
pinprick sensation, ankle reflexes, or
vibration perception threshold). (B)
Provide general foot self-care education
to all patients with diabetes. (B)
A multidisciplinary approach is recommended for individuals with foot ulcers
and high-risk feet, especially those with
a history of prior ulcer or amputation.
(B)
Refer patients who smoke, have loss of
protective sensation and structural abnormalities, or have history of prior
lower-extremity complications to foot
care specialists for ongoing preventive
care and life-long surveillance. (C)
Initial screening for peripheral arterial
disease (PAD) should include a history
for claudication and an assessment of
the pedal pulses. Consider obtaining an
ankle-brachial index (ABI), as many patients with PAD are asymptomatic. (C)
Refer patients with significant claudication or a positive ABI for further vascular assessment and consider exercise,
medications, and surgical options. (C)
Amputation and foot ulceration, consequences of diabetic neuropathy and/or
PAD, are common and major causes of
morbidity and disability in people with
diabetes. Early recognition and management of risk factors can prevent or delay
adverse outcomes.
The risk of ulcers or amputations is
increased in people who have the following risk factors:
Previous amputation
Past foot ulcer history
Peripheral neuropathy
Foot deformity
Peripheral vascular disease
Visual impairment
Diabetic nephropathy (especially patients on dialysis)
Poor glycemic control
Cigarette smoking
Many studies have been published proposing a range of tests that might usefully
identify patients at risk of foot ulceration,
creating confusion among practitioners as
to which screening tests should be
adopted in clinical practice. An ADA task
force was therefore assembled in 2008 to
concisely summarize recent literature in
this area and then recommend what
should be included in the comprehensive
foot exam for adult patients with diabetes.
Their recommendations are summarized
below, but clinicians should refer to the
task force report (305) for further details
and practical descriptions of how to perform components of the comprehensive
foot examination.
At least annually, all adults with diabetes should undergo a comprehensive
foot examination to identify high risk
conditions. Clinicians should ask about
history of previous foot ulceration or amputation, neuropathic or peripheral vascular symptoms, impaired vision, tobacco
use, and foot care practices. A general inspection of skin integrity and musculoskeletal deformities should be done in a
well lit room. Vascular assessment would
include inspection and assessment of
pedal pulses.
The neurologic exam recommended
is designed to identify loss of protective
sensation (LOPS) rather than early neuropathy. The clinical examination to identify LOPS is simple and requires no
expensive equipment. Five simple clinical
tests (use of a 10-g monofilament, vibration testing using a 128-Hz tuning fork,
tests of pinprick sensation, ankle reflex
assessment, and testing vibration perception threshold with a biothesiometer),
each with evidence from well-conducted
prospective clinical cohort studies, are
considered useful in the diagnosis of
LOPS in the diabetic foot. The task force
agrees that any of the five tests listed could
be used by clinicians to identify LOPS,
although ideally two of these should be
regularly performed during the screening
examnormally the 10-g monofilament
and one other test. One or more abnormal
tests would suggest LOPS, while at least
two normal tests (and no abnormal test)
would rule out LOPS. The last test listed,
vibration assessment using a biothesiometer or similar instrument, is widely used
S37

in the U.S.; however, identification of the
patient with LOPS can easily be carried
out without this or other expensive equipment.
Initial screening for PAD should include a history for claudication and an
assessment of the pedal pulses. A diagnostic ABI should be performed in any patient with symptoms of PAD. Due to the
high estimated prevalence of PAD in patients with diabetes and the fact that many
patients with PAD are asymptomatic, an
ADA consensus statement on PAD (306)
suggested that a screening ABI be performed in patients over 50 years of age
and be considered in patients under 50
years of age who have other PAD risk factors (e.g., smoking, hypertension, hyperlipidemia, or duration of diabetes 10
years). Refer patients with significant
symptoms or a positive ABI for further
vascular assessment and consider exercise, medications, and surgical options
(306).
Patients with diabetes and high-risk
foot conditions should be educated regarding their risk factors and appropriate
management. Patients at risk should understand the implications of the LOPS,
the importance of foot monitoring on a
daily basis, the proper care of the foot,
including nail and skin care, and the selection of appropriate footwear. Patients
with LOPS should be educated on ways to
substitute other sensory modalities (hand
palpation, visual inspection) for surveillance of early foot problems. Patients understanding of these issues and their
physical ability to conduct proper foot
surveillance and care should be assessed.
Patients with visual difficulties, physical
constraints preventing movement, or cognitive problems that impair their ability to
assess the condition of the foot and to institute appropriate responses will need
other people, such as family members, to
assist in their care.
People with neuropathy or evidence
of increased plantar pressure (e.g., erythema, warmth, callus, or measured pressure) may be adequately managed with
well-fitted walking shoes or athletic shoes
that cushion the feet and redistribute
pressure. Callus can be debrided with a
scalpel by a foot care specialist or other
health professional with experience and
training in foot care. People with bony
deformities (e.g., hammertoes, prominent metatarsal heads, bunions) may
need extra-wide or -depth shoes. People
with extreme bony deformities (e.g.,
Charcot foot) who cannot be accommoS38
dated with commercial therapeutic footwear may need custom-molded shoes.

Foot ulcers and wound care may require care by a podiatrist, orthopedic or
vascular surgeon, or rehabilitation specialist experienced in the management of
individuals with diabetes.
VII. DIABETES CARE IN
SPECIFIC POPULATIONS
A. Children and adolescents
1. Type 1 diabetes
Three-quarters of all cases of type 1 diabetes are diagnosed in individuals 18
years of age. It is appropriate to consider
the unique aspects of care and management of children and adolescents with
type 1 diabetes. Children with diabetes
differ from adults in many respects, including changes in insulin sensitivity related to sexual maturity and physical
growth, ability to provide self-care, supervision in child care and school, and
unique neurological vulnerability to hypoglycemia and DKA. Attention to such
issues as family dynamics, developmental
stages, and physiological differences related to sexual maturity are all essential in
developing and implementing an optimal
diabetes regimen. Although recommendations for children and adolescents are
less likely to be based on clinical trial evidence, expert opinion and a review of
available and relevant experimental data
are summarized in the ADA statement on
care of children and adolescents with type
1 diabetes (307).
Ideally, the care of a child or adolescent with type 1 diabetes should be provided by a multidisciplinary team of
specialists trained in the care of children
with pediatric diabetes. At the very least,
education of the child and family should
be provided by health care providers
trained and experienced in childhood diabetes and sensitive to the challenges
posed by diabetes in this age-group. At
the time of initial diagnosis, it is essential
that diabetes education be provided in a
timely fashion, with the expectation that
the balance between adult supervision
and self-care should be defined by, and
will evolve according to, physical, psychological, and emotional maturity. MNT
and psychological support should be provided at diagnosis, and regularly thereafter, by individuals experienced with the
nutritional and behavioral needs of the
growing child and family.
a. Glycemic control
Recommendations
Consider age when setting glycemic
goals in children and adolescents with
type 1 diabetes. (E)
While current standards for diabetes

management reflect the need to maintain
glucose control as near to normal as safely
possible, special consideration should be
given to the unique risks of hypoglycemia
in young children. Glycemic goals may
need to be modified to take into account
the fact that most children 6 or 7 years
of age have a form of hypoglycemic unawareness, including immaturity of and
a relative inability to recognize and respond to hypoglycemic symptoms, placing them at greater risk for severe
hypoglycemia and its sequelae. In addition, and unlike the case in adults, young
children under the age of 5 years may be
at risk for permanent cognitive impairment after episodes of severe hypoglycemia (308 310). Furthermore, findings
from the DCCT demonstrated that nearnormalization of blood glucose levels was
more difficult to achieve in adolescents
than adults. Nevertheless, the increased
frequency of use of basal-bolus regimens
and insulin pumps in youth from infancy
through adolescence has been associated
with more children reaching ADA blood
glucose targets (311,312) in those families in which both parents and the child
with diabetes participate jointly to perform the required diabetes-related tasks.
Furthermore, recent studies documenting neurocognitive sequelae of hyperglycemia in children provide another
compelling motivation for achieving glycemic targets (313,314).
In selecting glycemic goals, the benefits on long-term health outcomes of
achieving a lower A1C should be balanced against the risks of hypoglycemia
and the developmental burdens of intensive regimens in children and youth. Agespecific glycemic and A1C goals are
presented in Table 16.
b. Screening and management of
chronic complications in children
and adolescents with type 1 diabetes
i. Nephropathy
Recommendations
Annual screening for microalbuminuria, with a random spot urine sample
Position Statement
Table 16Plasma blood glucose and A1C goals for type 1 diabetes by age-group
Plasma blood glucose goal range
(mg/dl)
Before meals
Bedtime/overnight
A1C (%)
Rationale
Toddlers and preschoolers

(06 years)
100180
110200
8.5
Vulnerability to hypoglycemia
Insulin sensitivity
Unpredictability in dietary intake and
physical activity
A lower goal (8.0%) is reasonable if
it can be achieved without excessive
hypoglycemia
School age (612 years)
90180
100180
Vulnerability to hypoglycemia
hypoglycemia
Adolescents and young adults

(1319 years)
90130
90150
7.5

hypoglycemia
Key concepts in setting glycemic goals

Goals should be individualized and lower goals may be reasonable based on benefit-risk
assessment.
Blood glucose goals should be modified in children with frequent hypoglycemia or
hypoglycemia unawareness.
Postprandial blood glucose values should be measured when there is a discrepancy
between pre-prandial blood glucose values and A1C levels and to help assess glycemia in
those on basal/bolus regimens.
for albumin-to-creatinine (ACR) ratio, should be considered once the

child is 10 years of age and has had
diabetes for 5 years. (E)
Confirmed, persistently elevated ACR
on two additional urine specimens
from different days should be treated
with an ACE inhibitor, titrated to normalization of albumin excretion if
possible. (E)
ii. Hypertension
Recommendations
Treatment of high-normal blood
pressure (systolic or diastolic blood
pressure consistently above the 90th
percentile for age, sex, and height)
should include dietary intervention
and exercise aimed at weight control
and increased physical activity, if appropriate. If target blood pressure is
not reached with 3 6 months of lifestyle intervention, pharmacologic
treatment should be considered. (E)
Pharmacologic treatment of hypertension (systolic or diastolic blood
pressure consistently above the 95th
percentile for age, sex, and height or

consistently greater than 130/80
mmHg, if 95% exceeds that value)
should be initiated as soon as the diagnosis is confirmed. (E)
ACE inhibitors should be considered
for the initial treatment of hypertension, following appropriate reproductive counseling due to its potential
teratogenic effects. (E)
The goal of treatment is a blood pressure consistently 130/80 or below the
90th percentile for age, sex, and height,
whichever is lower. (E)
It is important that blood pressure measurements are determined correctly, using the appropriate size cuff, and with
the child seated and relaxed. Hypertension should be confirmed on at least
three separate days. Normal blood pressure levels for age, sex, and height and
appropriate methods for determinations are available online at www.nhlbi.
nih.gov/health/prof/heart/hbp/hbp_
ped.pdf.
iii. Dyslipidemia
Recommendations
Screening
If there is a family history of hypercholesterolemia (total cholesterol 240
mg/dl) or a cardiovascular event before
age 55 years, or if family history is unknown, then a fasting lipid profile
should be performed on children 2
years of age soon after diagnosis (after
glucose control has been established).
If family history is not of concern, then
the first lipid screening should be considered at puberty (10 years). All children diagnosed with diabetes at or after
puberty should have a fasting lipid profile performed soon after diagnosis
(after glucose control has been established). (E)
For both age-groups, if lipids are abnormal, annual monitoring is recommended. If LDL cholesterol values are
within the accepted risk levels (100
mg/dl [2.6 mmol/l]), a lipid profile
should be repeated every 5 years. (E)
S39

Treatment
Initial therapy should consist of optimization of glucose control and MNT using a Step 2 AHA diet aimed at a
decrease in the amount of saturated fat
in the diet. (E)
After the age of 10 years, the addition of
a statin in patients who, after MNT and
lifestyle changes, have LDL cholesterol
160 mg/dl (4.1 mmol/l), or LDL cholesterol 130 mg/dl (3.4 mmol/l) and
one or more CVD risk factors, is reasonable. (E)
The goal of therapy is an LDL cholesterol value 100 mg/dl (2.6 mmol/l).
(E)
Although retinopathy most commonly

occurs after the onset of puberty and after
510 years of diabetes duration, it has
been reported in prepubertal children
and with diabetes duration of only 12
years. Referrals should be made to eye
care professionals with expertise in diabetic retinopathy, an understanding of
the risk for retinopathy in the pediatric
population, and experience in counseling the pediatric patient and family on
the importance of early prevention/
intervention.
People diagnosed with type 1 diabetes in

childhood have a high risk of early subclinical (315317) and clinical (318)
CVD. Although intervention data are
lacking, the AHA categorizes children
with type 1 diabetes in the highest tier for
cardiovascular risk and recommends
both lifestyle and pharmacologic treatment for those with elevated LDL cholesterol levels (319,320). Initial therapy
should be with a Step 2 AHA diet, which
restricts saturated fat to 7% of total calories and restricts dietary cholesterol to
200 mg/day. Data from randomized clinical trials in children as young as 7
months of age indicate that this diet is safe
and does not interfere with normal
growth and development (321,322).
Neither long-term safety nor cardiovascular outcome efficacy of statin therapy has been established for children.
However, recent studies have shown
short-term safety equivalent to that seen
in adults, and efficacy in lowering LDL
cholesterol levels, improving endothelial
function, and causing regression of carotid intimal thickening (323325). No
statin is approved for use under the age of
10 years, and statin treatment should generally not be used in children with type 1
diabetes prior to this age.
iv. Retinopathy
Recommendations
The first ophthalmologic examination
should be obtained once the child is 10
years of age and has had diabetes for
35 years. (E)
After the initial examination, annual
routine follow-up is generally recommended. Less frequent examinations
may be acceptable on the advice of an
eye care professional. (E)
S40
v. Celiac disease
Recommendations
Children with type 1 diabetes should
be screened for celiac disease by measuring tissue transglutaminase or
anti-endomysial antibodies, with
documentation of normal total serum
IgA levels, soon after the diagnosis of
diabetes. (E)
Testing should be repeated in children
with growth failure, failure to gain
weight, weight loss, diarrhea, flatulence, abdominal pain, or signs of malabsorption, or in children with
frequent unexplained hypoglycemia or
deterioration in glycemic control. (E)
Children with positive antibodies
should be referred to a gastroenterologist for evaluation with endoscopy and
biopsy. (E)
Children with biopsy-confirmed celiac
disease should be placed on a glutenfree diet and have consultation with a
dietitian experienced in managing both
diabetes and celiac disease. (E)
Celiac disease is an immune-mediated
disorder that occurs with increased frequency in patients with type 1 diabetes
(116% of individuals compared with
0.31% in the general population)
(326,327). Symptoms of celiac disease include diarrhea, weight loss or poor weight
gain, growth failure, abdominal pain,
chronic fatigue, malnutrition due to malabsorption, other gastrointestinal problems, and unexplained hypoglycemia or
erratic blood glucose concentrations.
The advent of routine periodic
screening has led to the diagnosis of celiac
disease in asymptomatic children. While
several studies have documented shortterm benefits of gluten restriction on
growth and bone mineral density in
asymptomatic children diagnosed with
celiac disease by routine screening, there
is little literature available regarding the
long-term benefit of gluten-free diets in

this population.
vi. Hypothyroidism
Recommendations
Children with type 1 diabetes should be
screened for thyroid peroxidase and
thyroglobulin antibodies at diagnosis.
(E)
TSH concentrations should be measured after metabolic control has been
established. If normal, they should be
re-checked every 12 years, or if the
patient develops symptoms of thyroid
dysfunction, thyromegaly, or an abnormal growth rate. (E)
Auto-immune thyroid disease is the most

common autoimmune disorder associated with diabetes, occurring in 1730%
of patients with type 1 diabetes (328). The
presence of thyroid auto-antibodies is
predictive of thyroid dysfunction, generally hypothyroidism but less commonly
hyperthyroidism (329). Subclinical hypothyroidism may be associated with
increased risk of symptomatic hypoglycemia (330) and with reduced linear growth
(331). Hyperthyroidism alters glucose
metabolism, potentially resulting in deterioration of metabolic control.
c. Self-management
No matter how sound the medical regimen, it can only be as good as the ability of
the family and/or individual to implement
it. Family involvement in diabetes remains an important component of optimal diabetes management throughout
childhood and into adolescence. Health
care providers who care for children and
adolescents, therefore, must be capable of
evaluating the behavioral, emotional, and
psychosocial factors that interfere with
implementation and then must work with
the individual and family to resolve problems that occur and/or to modify goals as
appropriate.
d. School and day care
Because a sizable portion of a childs day is
spent in school, close communication
with and cooperation of school or day
care personnel is essential for optimal diabetes management, safety, and maximal
academic opportunities. See the ADA position statement on Diabetes Care in the
School and Day Care Setting (332) for further discussion.
Position Statement
e. Transition from pediatric to adult
care
As they approach the young adult years,
older adolescents are at increasing physical, behavioral, and other risks (333,334).
As they leave both their home and their
pediatric diabetes care providers, these
older teens may become disengaged from
the health care system, leading to lapses in
medical care and deterioration in glycemic control (335). Though scientific evidence is limited to date, it is clear that
early and ongoing attention be given to
comprehensive and coordinated planning
for seamless transition of all youth from
pediatric to adult health care (336,337).
The National Diabetes Education Program (NDEP) has materials available to
facilitate this transition process (http://
ndep.nih.gov/transitions/).
2. Type 2 diabetes
The incidence of type 2 diabetes in adolescents is increasing, especially in ethnic
minority populations (21). Distinction
between type 1 and type 2 diabetes in
children can be difficult, since the prevalence of overweight in children continues
to rise and since autoantigens and ketosis
may be present in a substantial number of
patients with features of type 2 diabetes
(including obesity and acanthosis nigricans). Such a distinction at the time of
diagnosis is critical since treatment regimens, educational approaches, and dietary counsel will differ markedly
between the two diagnoses.
Type 2 diabetes has a significant prevalence of comorbidities already present at the
time of diagnosis (338). It is recommended
that blood pressure measurement, a fasting
lipid profile, microalbuminuria assessment,
and dilated eye examination be performed
at the time of diagnosis. Thereafter, screening guidelines and treatment recommendations for hypertension, dyslipidemia,
microalbuminuria, and retinopathy in
youth with type 2 diabetes are similar to
those for youth with type 1 diabetes. Additional problems that may need to be addressed include polycystic ovary disease
and the various comorbidities associated
with pediatric obesity such as sleep apnea, hepatic steatosis, orthopedic complications, and psychosocial concerns. The
ADA consensus statement on this subject
(23) provides guidance on the prevention, screening, and treatment of type 2
diabetes and its comorbidities in young
people.
3. Monogenic diabetes syndromes

Monogenic forms of diabetes (neonatal
diabetes or maturity-onset diabetes of the
young) represent a small fraction of children with diabetes (5%), but the ready
availability of commercial genetic testing
is now enabling a true genetic diagnosis
with increasing frequency. It is important
to correctly diagnose one of the monogenic forms of diabetes, as these children
may be incorrectly diagnosed with type 1
or type 2 diabetes, leading to nonoptimal
treatment regimens and delays in diagnosing other family members.
The diagnosis of monogenic diabetes
should be considered in the following settings: diabetes diagnosed within the first 6
months of life; in children with strong
family history of diabetes but without typical features of type 2 diabetes (nonobese,
low-risk ethnic group); in children with
mild fasting hyperglycemia (100 150
mg/dl [5.5 8.5 mmol]), especially if
young and nonobese; and in children
with diabetes but with negative autoantibodies without signs of obesity or insulin resistance. A recent international
consensus document discusses in further
detail the diagnosis and management of
children with monogenic forms of diabetes (339).
B. Preconception care
Recommendations
A1C levels should be as close to normal
as possible (7%) in an individual patient before conception is attempted.
(B)
Starting at puberty, preconception
counseling should be incorporated in
the routine diabetes clinic visit for all
women of child-bearing potential. (C)
Women with diabetes who are contemplating pregnancy should be evaluated
and, if indicated, treated for diabetic
retinopathy, nephropathy, neuropathy,
and CVD. (E)
Medications used by such women
should be evaluated prior to conception, since drugs commonly used to
treat diabetes and its complications
may be contraindicated or not recommended in pregnancy, including statins, ACE inhibitors, ARBs, and most
noninsulin therapies. (E)
Since many pregnancies are unplanned, consider the potential risks
and benefits of medications that are
contraindicated in pregnancy in all
women of childbearing potential, and
counsel women using such medications accordingly. (E)

Major congenital malformations remain
the leading cause of mortality and serious
morbidity in infants of mothers with type
1 and type 2 diabetes. Observational studies indicate that the risk of malformations
increases continuously with increasing
maternal glycemia during the first 6 8
weeks of gestation, as defined by firsttrimester A1C concentrations. There is no
threshold for A1C values below which
risk disappears entirely. However, malformation rates above the 12% background rate of nondiabetic pregnancies
appear to be limited to pregnancies in
which first-trimester A1C concentrations
are 1% above the normal range for a
nondiabetic pregnant woman.
Preconception care of diabetes appears to reduce the risk of congenital malformations. Five nonrandomized studies
compared rates of major malformations in
infants between women who participated
in preconception diabetes care programs
and women who initiated intensive diabetes management after they were already
pregnant. The preconception care programs were multidisciplinary and designed to train patients in diabetes selfmanagement with diet, intensified insulin
therapy, and SMBG. Goals were set to
achieve normal blood glucose concentrations, and 80% of subjects achieved
normal A1C concentrations before they
became pregnant. In all five studies, the
incidence of major congenital malformations in women who participated in preconception care (range 1.0 1.7% of
infants) was much lower than the incidence in women who did not participate
(range 1.4 10.9% of infants) (78). One
limitation of these studies is that participation in preconception care was selfselected rather than randomized. Thus, it
is impossible to be certain that the lower
malformation rates resulted fully from
improved diabetes care. Nonetheless, the
evidence supports the concept that malformations can be reduced or prevented
by careful management of diabetes before
pregnancy.
Planned pregnancies greatly facilitate preconception diabetes care. Unfortunately, nearly two-thirds of
pregnancies in women with diabetes are
unplanned, leading to a persistent excess of malformations in infants of diabetic mothers. To minimize the
occurrence of these devastating malformations, standard care for all women
S41

with diabetes who have child-bearing
potential, beginning at the onset of puberty or at diagnosis, should include 1)
education about the risk of malformations associated with unplanned pregnancies and poor metabolic control;
and 2) use of effective contraception at
all times, unless the patient has good
metabolic control and is actively trying
to conceive.
Women contemplating pregnancy
need to be seen frequently by a multidisciplinary team experienced in the
management of diabetes before and
during pregnancy. The goals of preconception care are to 1) involve and empower the patient in the management of
her diabetes, 2) achieve the lowest A1C
test results possible without excessive
hypoglycemia, 3) assure effective contraception until stable and acceptable
glycemia is achieved, and 4) identify,
evaluate, and treat long-term diabetes
complications such as retinopathy, nephropathy, neuropathy, hypertension,
and CHD (78).
Among the drugs commonly used in
the treatment of patients with diabetes,
a number may be relatively or absolutely contraindicated during pregnancy. Statins are category X
(contraindicated for use in pregnancy)
and should be discontinued before conception, as should ACE inhibitors
(340). ARBs are category C (risk cannot
be ruled out) in the first trimester but
category D (positive evidence of risk) in
later pregnancy and should generally be
discontinued before pregnancy. Since
many pregnancies are unplanned,
health care professionals caring for any
woman of childbearing potential should
consider the potential risks and benefits
of medications that are contraindicated
in pregnancy. Women using medications such as statins or ACE inhibitors
need ongoing family planning counseling. Among the oral antidiabetic agents,
metformin and acarbose are classified as
category B (no evidence of risk in humans) and all others as category C. Potential risks and benefits of oral
antidiabetic agents in the preconception
period must be carefully weighed, recognizing that data are insufficient to establish the safety of these agents in
pregnancy.
For further discussion of preconception care, see the ADAs consensus statement on preexisting diabetes and
pregnancy (78) and the position statement (341) on this subject.
S42
C. Older adults
Recommendations
Older adults who are functional, cognitively intact, and have significant life
expectancy should receive diabetes care
using goals developed for younger
adults. (E)
Glycemic goals for older adults not
meeting the above criteria may be relaxed using individual criteria, but hyperglycemia leading to symptoms or
risk of acute hyperglycemic complications should be avoided in all patients.
(E)
Other cardiovascular risk factors
should be treated in older adults with
consideration of the time frame of benefit and the individual patient. Treatment of hypertension is indicated in
virtually all older adults, and lipid and
aspirin therapy may benefit those with
life expectancy at least equal to the time
frame of primary or secondary prevention trials. (E)
Screening for diabetes complications
should be individualized in older
adults, but particular attention should
be paid to complications that would
lead to functional impairment. (E)
Diabetes is an important health condition

for the aging population; at least 20% of
patients over the age of 65 years have diabetes, and this number can be expected
to grow rapidly in the coming decades.
Older individuals with diabetes have
higher rates of premature death, functional disability, and coexisting illnesses
such as hypertension, CHD, and stroke
than those without diabetes. Older adults
with diabetes are also at greater risk than
other older adults for several common geriatric syndromes, such as polypharmacy,
depression, cognitive impairment, urinary incontinence, injurious falls, and
persistent pain.
The American Geriatric Societys
guidelines for improving the care of the
older person with diabetes (342) have influenced the following discussion and
recommendations. The care of older
adults with diabetes is complicated by
their clinical and functional heterogeneity. Some older individuals developed diabetes years earlier and may have
significant complications; others who are
newly diagnosed may have had years of
undiagnosed diabetes with resultant complications or may have few complications
from the disease. Some older adults with
diabetes are frail and have other underly-
ing chronic conditions, substantial diabetes-related comorbidity, or limited

physical or cognitive functioning. Other
older individuals with diabetes have little
comorbidity and are active. Life expectancies are highly variable for this population, but often longer than clinicians
realize. Providers caring for older adults
with diabetes must take this heterogeneity
into consideration when setting and prioritizing treatment goals.
There are few long-term studies in
older adults demonstrating the benefits of
intensive glycemic, blood pressure, and
lipid control. Patients who can be expected
to live long enough to reap the benefits of
long-term intensive diabetes management
and who are active, have good cognitive
function, and are willing should be provided with the needed education and skills
to do so and be treated using the goals for
younger adults with diabetes.
For patients with advanced diabetes
complications, life-limiting comorbid illness, or substantial cognitive or functional impairment, it is reasonable to set
less-intensive glycemic target goals. These
patients are less likely to benefit from reducing the risk of microvascular complications and more likely to suffer serious
adverse effects from hypoglycemia.
However, patients with poorly controlled
diabetes may be subject to acute complications of diabetes, including dehydration, poor wound healing, and
hyperglycemic hyperosmolar coma. Glycemic goals at a minimum should avoid
these consequences.
Although control of hyperglycemia
may be important in older individuals
with diabetes, greater reductions in morbidity and mortality may result from control of other cardiovascular risk factors
rather than from tight glycemic control
alone. There is strong evidence from clinical trials of the value of treating hypertension in the elderly (343,344). There is
less evidence for lipid-lowering and aspirin therapy, although the benefits of these
interventions for primary and secondary
prevention are likely to apply to older
adults whose life expectancies equal or
exceed the time frames seen in clinical
trials.
Special care is required in prescribing
and monitoring pharmacologic therapy in
older adults. Metformin is often contraindicated because of renal insufficiency or
significant heart failure. TZDs can cause
fluid retention, which may exacerbate or
lead to heart failure. They are contraindicated in patients with CHF (New York
Position Statement
Heart Association class III and class IV)
and if used at all should be used very cautiously in those with, or at risk for, milder
degrees of CHF. Sulfonylureas, other insulin secretagogues, and insulin can cause
hypoglycemia. Insulin use requires that
patients or caregivers have good visual
and motor skills and cognitive ability.
Drugs should be started at the lowest dose
and titrated up gradually until targets are
reached or side effects develop.
Screening for diabetes complications
in older adults also should be individualized. Particular attention should be paid
to complications that can develop over
short periods of time and/or that would
significantly impair functional status,
such as visual and lower-extremity complications.
D. Cystic fibrosisrelated diabetes
Cystic fibrosisrelated diabetes (CFRD) is
the most common comorbidity in persons
with CF, occurring in about 20% of adolescents and 40 50% of adults. The additional diagnosis of diabetes in this
population is associated with worse nutritional status, more-severe inflammatory
lung disease, and greater mortality from
respiratory failure. For reasons that are
not well understood, women with CFRD
are particularly vulnerable to excess morbidity and mortality. Insulin insufficiency
related to partial fibrotic destruction of
the islet mass is the primary defect in
CFRD. Genetically determined function
of the remaining -cells and insulin resistance associated with infection and inflammation may also play a role.
Encouraging new data suggest that early
detection and aggressive insulin therapy
have narrowed the gap in mortality between CF patients with and without diabetes, and have eliminated the sex
difference in mortality.
A consensus conference on CFRD
was co-sponsored in 2009 by the American Diabetes Association, the Cystic Fibrosis Foundation, and the Pediatric
Endocrine Society. Recommendations for
the clinical management of CFRD can be
found in an ADA position statement
(344a).
VIII. DIABETES CARE IN SPECIFIC
SETTINGS
A. Diabetes care in the hospital
Recommendations
All patients with diabetes admitted to
the hospital should have their diabetes
clearly identified in the medical record.

(E)
All patients with diabetes should have
an order for blood glucose monitoring,
with results available to all members of
the health care team. (E)
Goals for blood glucose levels:
Critically ill patients: Insulin therapy
should be initiated for treatment of
persistent hyperglycemia starting at a
threshold of no greater than 180
mg/dl (10 mmol/l). Once insulin
therapy is started, a glucose range of
140 180 mg/dl (7.8 10 mmol/l) is
recommended for the majority of
critically ill patients. (A)
More stringent goals, such as 110
140 mg/dl (6.17.8 mmol/l) may be
appropriate for selected patients, as
long as this can be achieved without
significant hypoglycemia. (C)
Critically ill patients require an intravenous insulin protocol that has
demonstrated efficacy and safety in
achieving the desired glucose range
without increasing risk for severe hypoglycemia. (E)
Non critically ill patients: There is
no clear evidence for specific blood
glucose goals. If treated with insulin,
the premeal blood glucose target
should generally be 140 mg/dl (7.8
mmol/l) with random blood glucose
180 mg/dl (10.0 mmol/l), provided
these targets can be safely achieved.
More stringent targets may be appropriate in stable patients with previous
tight glycemic control. Less stringent
targets may be appropriate in those
with severe comorbidites. (E)
Scheduled subcutaneous insulin with
basal, nutritional, and correction components is the preferred method for
achieving and maintaining glucose
control in noncritically ill patients. (C)
Using correction dose or supplemental insulin to correct premeal hyperglycemia in addition to scheduled
prandial and basal insulin is recommended. (E)
Glucose monitoring should be initiated
in any patient not known to be diabetic
who receives therapy associated with
high risk for hyperglycemia, including
high-dose glucocorticoid therapy, initiation of enteral or parenteral nutrition,
or other medications such as octreotide
or immunosuppressive medications.
(B) If hyperglycemia is documented
and persistent, treatment is necessary.
Such patients should be treated to the
same glycemic goals as patients with

known diabetes. (E)
A hypoglycemia management protocol
should be adopted and implemented
by each hospital or hospital system. A
plan for treating hypoglycemia should
be established for each patient. Episodes of hypoglycemia in the hospital
should be documented in the medial
record and tracked. (E)
All patients with diabetes admitted to
the hospital should have an A1C obtained if the result of testing in the previous 23 months is not available. (E)
Patients with hyperglycemia in the hospital who do not have a diagnosis of
diabetes should have appropriate plans
for follow-up testing and care documented at discharge. (E)
Hyperglycemia in the hospital is extensively reviewed in an ADA technical review (345). A recent updated consensus
statement by the American Association of
Clinical Endocrinologists (AACE) and the
ADA (346) forms the basis for the discussion and guidelines in this section.
The literature on hospitalized patients with hyperglycemia typically describes three categories:
1. Medical history of diabetes: diabetes
has been previously diagnosed and acknowledged by the patients treating
physician.
2. Unrecognized diabetes: hyperglycemia
(fasting blood glucose 126 mg/dl or
random blood glucose 200 mg/dl)
occurring during hospitalization and
confirmed as diabetes after hospitalization by standard diagnostic criteria but
unrecognized as diabetes by the treating physician during hospitalization.
3. Hospital-related hyperglycemia: hyperglycemia (fasting blood glucose
126 mg/dl or random blood glucose
200 mg/dl) occurring during the
hospitalization that reverts to normal
after hospital discharge.
The management of hyperglycemia in the
hospital has often been considered secondary in importance to the condition
that prompted admission (345). However, a body of literature now supports
targeted glucose control in the hospital
setting for potential improved clinical
outcomes. Hyperglycemia in the hospital
may result from stress, decompensation
of type 1 or type 2 or other forms of diabetes, and/or may be iatrogenic due to
withholding of anti-hyperglycemic medi-
S43

cations or administration of hyperglycemia-provoking agents such as
glucocorticoids or vasopressors.
People with diabetes are more likely
to be hospitalized and to have longer
lengths of stay than those without diabetes. A recent survey estimated that 22% of
all hospital inpatient days were incurred
by people with diabetes and that hospital
inpatient care accounted for half of the
$174 billion total U.S. medical expenditures for this disease (347). This is due, in
part, to the continued expansion of the
worldwide epidemic of type 2 diabetes.
While the costs of illness-related stress
hyperglycemia are not known, they are
likely to be significant given the poor
prognosis of such patients (348 351).
There is substantial observational evidence linking hyperglycemia in hospitalized patients (with or without diabetes) to
poor outcomes. Cohort studies as well as
a few early randomized controlled trials
(RCTs) suggested that intensive treatment
of hyperglycemia improved hospital outcomes (345,350,351). In general, these
studies were heterogeneous in terms of
patient population, blood glucose targets
and insulin protocols, provision of nutritional support, and the proportion of patients receiving insulin, which limits the
ability to make meaningful comparisons
among them. Recent trials in critically ill
patients have failed to show a significant
improvement in mortality with intensive
glycemic control (352,353) or have even
shown increased mortality risk (354).
Moreover, these recent RCTs have highlighted the risk of severe hypoglycemia
resulting from such efforts (352357).
The largest study to date, NICESUGAR, a multicenter, multinational
RCT, compared the effect of intensive glycemic control (target 81108 mg/dl,
mean blood glucose attained 115 mg/dl)
to standard glycemic control (target 144
180 mg/dl, mean blood glucose attained
144 mg/dl) on outcomes among 6,104
critically ill participants, the majority of
whom (95%) required mechanical ventilation (354). Ninety-day mortality was
significantly higher in the intensive versus
the conventional group (78 more deaths;
27.5% vs. 24.9%, P 0.02) in both surgical and medical patients. Mortality from
cardiovascular causes was more common
in the intensive group (76 more deaths;
41.6% vs. 35.8%; P 0.02). Severe hypoglycemia was also more common in the
intensively treated group (6.8% vs. 0.5%;
P 0.001). The precise reason for the
increased mortality in the tightly conS44
trolled group is unknown. The results of

this study lie in stark contrast to a famous
2001 single-center study that reported a
42% relative reduction in intensive-care
unit (ICU) mortality in critically ill surgical patients treated to a target blood glucose of 80 110 mg/dl (350). Importantly,
the control group in NICE-SUGAR had
reasonably good blood glucose management maintained at a mean glucose of 144
mg/dl, only 29 mg/dl above the intensively managed patients. Accordingly,
this studys findings do not disprove the
notion that glycemic control in the ICU is
important. However, they do strongly
suggest that it is not necessary to target
blood glucose values 140 mg/dl, and
that a highly stringent target of 110
mg/dl may actually be dangerous.
In a recent meta-analysis of 26 trials
(N 13,567), which included the NICESUGAR data, the pooled relative risk (RR)
of death with intensive insulin therapy
was 0.93 as compared with conventional
therapy (95% CI 0.831.04) (357). Approximately half of these trials reported
hypoglycemia, with a pooled RR of intensive therapy of 6.0 (95% CI 4.5 8.0). The
specific ICU setting influenced the findings, with patients in surgical ICUs appearing to benefit from intensive insulin
therapy (RR 0.63 [95% CI 0.44 0.91]),
while those in other critical care settings
did not (medical ICU, RR 1.0 [95% CI
0.78 1.28]; mixed ICU, RR 0.99 [95%
CI 0.86 1.12]). It was concluded that
overall, intensive insulin therapy increased the risk of hypoglycemia but provided no overall benefit on mortality in
the critically ill, although a possible mortality benefit to patients admitted to the
surgical ICU (RR 0.63 [95% CI 0.44
0.91]) was suggested.
1. Glycemic targets in hospitalized
patients
Definition of glucose abnormalities
in the hospital setting
Hyperglycemia has been defined as any
blood glucose level 140 mg/dl (7.8
mmol/l). Levels that are significantly and
persistently above this may require treatment in hospitalized patients. In patients
without a previous diagnosis of diabetes,
elevated blood glucose may be due to
stress hyperglycemia, a condition that
can be established by a review of prior
records or measurement of an A1C. A1C
values 6.5% suggest that diabetes preceded hospitalization (358). Hypoglycemia has been defined as any blood glucose
level 70 mg/dl (3.9 mmol/l). This is the

standard definition in outpatients and
correlates with the initial threshold for the
release of counterregulatory hormones.
Severe hypoglycemia in hospitalized patients has been defined by many as 40
mg/dl (2.2 mmol/l), although this is lower
than the 50 mg/dl (2.8 mmol/l) level at
which cognitive impairment begins in
normal individuals (359). As with hyperglycemia, hypoglycemia among inpatients is also associated with adverse
short- and long-term outcomes. Early recognition and treatment of mild to moderate hypoglycemia (40 and 69 mg/dl) (2.2
and 3.8 mmol/l) can prevent deterioration to a more severe episode with potential adverse sequelae (346).
Critically ill patients
Based on the weight of the available evidence, for the majority of critically ill patients in the ICU setting, insulin infusion
should be used to control hyperglycemia,
with a starting threshold of no higher than
180 mg/dl (10.0 mmol/l). Once intravenous insulin is started, the glucose level
should be maintained between 140 and
180 mg/dl (7.8 and 10.0 mmol/l). Greater
benefit maybe realized at the lower end of
this range. Although strong evidence is
lacking, somewhat lower glucose targets
may be appropriate in selected patients.
However, targets less than 110 mg/dl (6.1
mmol/l) are not recommended. Use of insulin infusion protocols with demonstrated safety and efficacy, resulting in
low rates of hypoglycemia, are highly recommended (346).
Noncritically ill patients
With no prospective RCT data to inform
specific glycemic targets in noncritically
ill patients, recommendations are based
on clinical experience and judgment. For
the majority of noncritically ill patients
treated with insulin, premeal glucose targets should generally be 140 mg/dl (7.8
mmol/l) with random blood glucose levels 180 mg/dl (10.0 mmol/l), as long as
these targets can be safely achieved. To
avoid hypoglycemia, consideration
should be given to reassessing the insulin
regimen if blood glucose levels fall below
100 mg/dl (5.6 mmol/l). Modification of
the regimen is required when blood glucose values are 70 mg/dl (3.9 mmol/l),
unless the event is easily explained by
other factors (such as a missed meal, etc.)
Occasional patients with a prior history of successful tight glycemic control in
the outpatient setting who are clinically
Position Statement
stable may be maintained with a glucose
range below the above cut points. Conversely, higher glucose ranges may be acceptable in terminally ill patients or in
patients with severe comorbidities, as
well as in those in patient-care settings
where frequent glucose monitoring or
close nursing supervision is not feasible.
Clinical judgment, combined with
ongoing assessment of the patients clinical status, including changes in the trajectory of glucose measures, the severity of
illness, nutritional status, or concurrent
use of medications that might affect glucose levels (e.g., steroids, octreotide)
must be incorporated into the day-to-day
decisions regarding insulin dosing (346).
2. Anti-hyperglycemic agents in
hospitalized patients
In the hospital setting, insulin therapy is
the preferred method of glycemic control
in majority of clinical situations (346). In
the ICU, intravenous infusion is the preferred route of insulin administration.
When the patient is transitioned off intravenous insulin to subcutaneous therapy,
precautions should be taken to prevent
hyperglycemia escape (360,361). Outside
of critical care units, scheduled subcutaneous insulin which delivers basal, nutritional, and correction (supplemental)
components is preferred. Prolonged therapy with sliding scale insulin (SSI) as the
sole regimen is ineffective in the majority
of patients, increases risk of both hypoglycemia and hyperglycemia, and has recently been shown to be associated with
adverse outcomes in general surgery patients with type 2 diabetes (362). SSI is
potentially dangerous in type 1 diabetes
(346). The reader is referred to several
recent publications and reviews that describe currently available insulin preparations and protocols and provide guidance
in use of insulin therapy in specific clinical settings including parenteral nutrition
(363), enteral tube feedings, and with
high-dose glucocorticoid therapy (346).
There are no data on the safety and
efficacy of oral agents and injectable noninsulin therapies such as GLP1 analogs
and pramlintide in the hospital. They are
generally considered to have a limited role
in the management of hyperglycemia in
conjunction with acute illness. Continuation of these agents may be appropriate in
selected stable patients who are expected
to consume meals at regular intervals and
they may be initiated or resumed in anticipation of discharge once the patient is
clinically stable. Specific caution is recare.diabetesjournals.org
quired with metformin, due to the possibility that a contraindication may develop
during the hospitalization, such as renal
insufficiency, unstable hemodynamic status, or need for an imaging study that requires a radio-contrast dye.
hospital outcomes, hospitals will need

multidisciplinary support to develop insulin management protocols that effectively and safely enable achievement of
glycemic targets (366).
3. Preventing hypoglycemia
Hypoglycemia, especially in insulintreated patients, is the leading limiting
factor in the glycemic management of
type 1 and type 2 diabetes (173). In the
hospital, multiple additional risk factors
for hypoglycemia are present. Patients
with or without diabetes may experience
hypoglycemia in the hospital in association with altered nutritional state, heart
failure, renal or liver disease, malignancy,
infection, or sepsis. Additional triggering
events leading to iatrogenic hypoglycemia
include sudden reduction of corticosteroid dose, altered ability of the patient to
report symptoms, reduction of oral intake, emesis, new NPO status, inappropriate timing of short- or rapid-acting
insulin in relation to meals, reduction of
rate of administration of intravenous dextrose, and unexpected interruption of enteral feedings or parenteral nutrition.
Despite the preventable nature of
many inpatient episodes of hypoglycemia, institutions are more likely to have
nursing protocols for the treatment of hypoglycemia than for its prevention.
Tracking such episodes and analyzing
their causes are important quality improvement activities (346).
5. Self-management in the hospital

Self-management of diabetes in the hospital may be appropriate for competent
adult patients who: have a stable level of
consciousness, have reasonably stable
daily insulin requirements, successfully
conduct self-management of diabetes at
home, have physical skills needed to successfully self-administer insulin and perform SMBG, have adequate oral intake,
and are proficient in carbohydrate counting, use of multiple daily insulin injections or insulin pump therapy, and sickday management. The patient and
physician, in consultation with nursing
staff, must agree that patient selfmanagement is appropriate under the
conditions of hospitalization.
Patients who use CSII pump therapy
in the outpatient setting can be candidates
for diabetes self-management in the hospital, provided that they have the mental
and physical capacity to do so (346). A
hospital policy and procedures delineating inpatient guidelines for CSII pump
therapy are advisable. The availability of
hospital personnel with expertise in CSII
therapy is essential. It is important that
nursing personnel document basal rates
and bolus doses taken on a regular basis
(at least daily).
4. Diabetes care providers in the

hospital
Inpatient diabetes management may be
effectively championed and/or provided
by primary care physicians, endocrinologists, intensivists, or hospitalists. Involvement of appropriately trained specialists
or specialty teams may reduce length of
stay, improve glycemic control, and improve outcomes (346). In the care of diabetes, implementation of standardized
order sets for scheduled and correctiondose insulin may reduce reliance on sliding-scale management. As hospitals move
to comply with meaningful use regulations for electronic health records, as
mandated by the Health Information
Technology Act, efforts should be made to
assure that all components of structured insulin order sets are incorporated into electronic insulin order sets (364,365).
A team approach is needed to establish hospital pathways. To achieve glycemic targets associated with improved
6. DSME in the hospital

Teaching diabetes self-management to
patients in hospitals is a challenging task.
Patients are ill, under increased stress related to their hospitalization and diagnosis, and in an environment not conducive
to learning. Ideally, people with diabetes
should be taught at a time and place conducive to learningas an outpatient in a
recognized program of diabetes education.
For the hospitalized patient, diabetes
survival skills education is generally a
feasible approach. Patients and/or family
members receive sufficient information
and training to enable safe care at home.
Those newly diagnosed with diabetes or
who are new to insulin and/or blood glucose monitoring need to be instructed
before discharge. Those patients hospitalized because of a crisis related to diabetes
management or poor care at home need
education to prevent subsequent episodes
of hospitalization. An assessment of the
S45

need for a home health referral or referral
to an outpatient diabetes education program should be part of discharge planning for all patients.
7. MNT in the hospital
The goals of MNT are to optimize glycemic control, to provide adequate calories
to meet metabolic demands, and to create
a discharge plan for follow-up care
(345,367). ADA does not endorse any
single meal plan or specified percentages
of macronutrients, and the term ADA
diet should no longer be used. Current
nutrition recommendations advise individualization based on treatment goals,
physiologic parameters, and medication
usage. Consistent carbohydrate meal
plans are preferred by many hospitals
since they facilitate matching the prandial
insulin dose to the amount of carbohydrate consumed (368). Because of the
complexity of nutrition issues in the hospital, a registered dietitian, knowledgeable and skilled in MNT, should serve as
an inpatient team member. The dietitian
is responsible for integrating information
about the patients clinical condition, eating, and lifestyle habits and for establishing treatment goals in order to determine
a realistic plan for nutrition therapy
(369,370).
8. Bedside blood glucose monitoring
Point-of-care (POC) blood glucose monitoring performed at the bedside is used to
guide insulin dosing. In the patient who is
receiving nutrition, the timing of glucose
monitoring should match carbohydrate
exposure. In the patient who is not receiving nutrition, glucose monitoring is performed every 4 to 6 h (371,372). More
frequent blood glucose testing ranging
from every 30 min to every 2 h is required
for patients on intravenous insulin infusions.
Safety standards should be established for blood glucose monitoring, prohibiting sharing of fingerstick lancing
devices, lancets, and needles to reduce the
risk of transmission of blood borne diseases. Shared lancing devices carry essentially the same risk as shared syringes and
needles (373).
Accuracy of blood glucose measurements using POC meters has limitations
that must be considered. Although the
FDA allows a 20% error for blood glucose meters, questions about the appropriateness of these criteria have been
raised (388). Glucose measures differ significantly between plasma and whole
S46
blood, terms that are often used interchangeably and can lead to misinterpretation. Most commercially available
capillary blood glucose meters introduce
a correction factor of 1.12 to report a
plasma adjusted value (374).
Significant discrepancies between
capillary, venous, and arterial plasma
samples have been observed in patients
with low or high hemoglobin concentrations, hypoperfusion, and the presence of
interfering substances particularly maltose, as contained in immunoglobulins
(375). Analytical variability has been described with several POC meters (376).
Increasingly, newer generation POC
blood glucose meters correct for variation
in hematocrit and for interfering substances. Any glucose result that does not
correlate with the patients status should
be confirmed through conventional laboratory sampling of plasma glucose. The
FDA has become increasingly concerned
about the use of POC blood glucose
meters in the hospital and is presently reviewing matters related to their use.
9. Discharge planning
Transition from the acute care setting is a
high-risk time for all patients, not just
those with diabetes or new hyperglycemia. Although there is an extensive literature concerning safe transition within
and from the hospital, little of it is specific
to diabetes (377). It is important to remember that diabetes discharge planning
is not a separate entity, but part of an
overall discharge plan. As such, discharge
planning begins at admission to the hospital and is updated as projected patient
needs change.
Inpatients may be discharged to varied settings, including home (with or
without visiting nurse services), assisted
living, rehabilitation, or skilled nursing
facilities. The latter two sites are generally
staffed by health professionals; therefore
diabetes discharge planning will be limited to communication of medication and
diet orders. For the patient who is discharged to assisted living or to home, the
optimal program will need to consider the
type and severity of diabetes, the effects of
the patients illness on blood glucose levels, and the capacities and desires of the
patient. Smooth transition to outpatient
care should be ensured. The Agency for
Healthcare Research and Quality recommends that at a minimum, discharge
plans include:
Medication reconciliation: The patients medications must be crosschecked to ensure that no chronic
medications were stopped and to ensure the safety of new prescriptions.
Whenever possible, prescriptions for
new or changed medication should be
filled and reviewed with the patient and
family at or before discharge
Structured discharge communication:
Information on medication changes,
pending tests and studies, and follow-up needs must be accurately and
promptly communicated to outpatient
physicians, as soon as possible after discharge.
Ideally the inpatient care providers or

case managers/discharge planners will
schedule follow-up visit(s) with the appropriate professionals, including primary care provider, endocrinologist, and
diabetes educator (378).
An outpatient follow-up visit with the
primary care provider, endocrinologist,
or diabetes educator within 1 month of
discharge is advised for all patients having
hyperglycemia in the hospital. Clear communication with outpatient providers either directly or via hospital discharge
summaries facilitates safe transitions to
outpatient care. Providing information regarding the cause or the plan for determining the cause of hyperglycemia,
related complications and comorbidities,
and recommended treatments can assist
outpatient providers as they assume ongoing care.
It is important that patients be provided with appropriate durable medical
equipment, medication, supplies, and
prescriptions at the time of discharge in
order to avoid a potentially dangerous hiatus in care. These supplies/prescriptions
should include:
Insulin (vials or pens) (if needed)

Syringes or pen needles (if needed)
Oral medications (if needed)
Blood glucose meter and strips
Lancets and lancing device
Urine ketone strips (type 1)
Glucagon emergency kit (insulintreated)
Medical alert application/charm
IX. STRATEGIES FOR

IMPROVING DIABETES
CARE There has been steady improvement in the proportion of diabetic
patients achieving recommended levels of
A1C, blood pressure, and LDL cholesterol
Position Statement
in the last 10 years, both in primary care
settings and in endocrinology practices.
Mean A1C nationally has declined from
7.82% in 1999 2000 to 7.18% in 2004
based on National Health and Nutrition
Examination Survey (NHANES) data
(379). This has been accompanied by improvements in lipids and blood pressure
control and led to substantial reductions
in end-stage microvascular complications
in those with diabetes (380). Nevertheless, in some studies only 57.1% of adults
with diagnosed diabetes achieved an A1C
of 7%, only 45.5% had a blood pressure
130/80 mmHg, and just 46.5% had a
total cholesterol 200 mg/dl, with only
12.2% of people with diabetes achieving
all three treatment goals (381). Moreover,
there is persistent variation in quality of
diabetes care across providers and across
practice settings even after adjusting for
patient factors that indicates the potential
for substantial further improvements in
diabetes care.
While numerous interventions to improve adherence to the recommended
standards have been implemented, a major contributor to suboptimal care is a delivery system that too often is fragmented,
lacks clinical information capabilities, often duplicates services, and is poorly designed for the delivery of chronic care.
The Chronic Care Model (CCM) includes
six core elements for the provision of optimal care of patients with chronic disease: 1) delivery system design (moving
from a reactive to a proactive care delivery
system, where planned visits are coordinated through a team-based approach; 2)
self-management support; 3) decision
support (basing care on consistent, effective care guidelines); 4) clinical information systems (using registries that can
provide patient-specific and populationbased support to the care team); 5)
community resources and policies (identifying or developing resources to support
healthy lifestyles); and 6) health systems
(to create a quality-oriented culture). Alterations in reimbursement that reward
the provision of quality care, as defined by
the attainment of evidence-based quality
measures, will also be required to achieve
desired outcome goals. Redefinition of the
roles of the clinic staff and promoting selfmanagement on the part of the patient are
fundamental to the successful implementation of the CCM (382). Collaborative,
multidisciplinary teams are best suited to
provide such care for people with chronic
conditions like diabetes and to facilitate
patients performance of appropriate selfmanagement.

A rapidly evolving literature suggests
that there are three major strategies to
successfully improve the quality of diabetes care delivered by a team of providers.
NDEP maintains an online resource
(www.betterdiabetescare.nih.gov) to help
health care professionals design and implement more effective health care delivery systems for those with diabetes.
Three specific objectives, with references to literature that outlines practical
strategies to achieve each, are outlined below.
Objective 1
Provider and team behavior change: Facilitate timely and appropriate intensification of lifestyle and/or pharmaceutical
therapy of patients who have not achieved
beneficial levels of blood pressure, lipid,
or glucose control.
Clinical information systems including

registries that can prospectively identify and track those requiring assessments and/or treatment modifications
by the team.
Electronic medical record-based clinical decision support at the point of care,
both personalize and standardize care
and can be used by multiple providers
(383).
Use of checklists and/or flow sheets that
mirror guidelines.
Detailed treatment algorithms enabling
multiple team members to treat to target and appropriately intensify therapy.
Availability of care or disease management services (384) by nurses, pharmacists, and other providers using
detailed algorithms often catalyzing reduction in A1C, blood pressure, and
LDL cholesterol (385,386).
Objective 3
Change the system of care: Research on
the comprehensive CCM suggests additional strategies to improve diabetes care,
including the following:
Objective 2
Patient behavior change: Implement a
systematic approach to support patients
behavior change efforts as needed including 1) healthy lifestyle (physical activity,
healthy eating, nonuse of tobacco, weight
management, effective coping, medication taking and management); 2) prevention of diabetes complications (screening
for eye, foot, and renal complications; immunizations); and 3) achievement of appropriate blood pressure, lipid, and
glucose goals.
Delivery of high-quality DSME, which

has been shown to improve patient selfmanagement, satisfaction, and glucose
control (115,387).
Delivery of ongoing diabetes selfmanagement support (DSMS) to ensure
that gains achieved during DSME are
sustained (128 129). National DSME
standards call for an integrated approach that includes clinical content
and skills, behavioral strategies (goalsetting, problem solving), and addressing emotional concerns in each needed
curriculum content area. Provision of
continuing education and support
(DSMS) improves maintenance of gains
regardless of the educational methodology (89).
Provision of automated reminders via
multiple communication channels to
various subgroups of diabetic patients
(96).
Basing care on consistent, evidencebased care guidelines

Redefining and expanding the roles of
the clinic staff (382)
Collaborative, multidisciplinary teams
to provide high-quality care and support patients appropriate selfmanagement
Audit and feedback of process and outcome data to providers to encourage
population-based care improvement
strategies
Care management, one of the most effective diabetes quality improvement
strategies to improve glycemic control
(384).
Identifying and/or developing community resources and public policy that
support healthy lifestyles
Alterations in reimbursement that reward the provision of appropriate and
high-quality care and accommodate the
need to personalize care goals, providing additional incentives to improve diabetes care (382,388 392)
The most successful practices have an institutional priority for quality of care, expanding the role of teams and staff,
redesigning their delivery system, activating and educating their patients, and using electronic health record tools
(393,394). Recent initiatives such as the
S47

Patient Centered Medical Home show
promise in improving outcomes through
coordinated primary care and offer new
opportunities for team-based chronic disease care (395).
It is clear that optimal diabetes management requires an organized, systematic approach and involvement of a
coordinated team of dedicated health care
professionals working in an environment
where patient-centered high-quality care
is a priority.
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P O S I T I O N

Standards of Medical Care in Diabetes2011

Originally approved 1988. Most recent review/revision October 2010.

4. Diabetes care providers in the

iabetes is a chronic illness that requires continuing medical care and

DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011

Standards of Medical Care

tion is listed after each recommendation

Type 1 diabetes (results from -cell destruction, usually leading to absolute

Some patients cannot be clearly classified

DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011

However, in practice, a large portion of

variability of all the tests, it is also possible

Table 3Categories of increased risk for diabetes (prediabetes)*

compared with an A1C of 5.0% (10). In a

DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011

Standards of Medical Care

To test for diabetes or to assess risk of

A. Testing for type 2 diabetes and

DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011

complications of diabetes within 3 years

test various methods of preventing type 1

for detection and classification of GDM,

Table 6Screening for and diagnosis of

optimizing gestational outcomes for

DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011

Standards of Medical Care

522 IGT, BMI 25 kg/m2

2,155* IGT, BMI 24 kg/m2,

abetes (1319). These interventions

DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011

loss and moderate physical activity of at

Table 8Components of the comprehensive diabetes evaluation

For patients using less-frequent insulin

in conjunction with intensive insulin

DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011

Standards of Medical Care

hyperglycemic excursions. Small studies

DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011

Table 9Correlation of A1C with average

These estimates are based on ADAG data of 2,700

quency of A1C testing should be

the diagnosis of diabetes, is associated

Glycemic control is fundamental to the

The Veterans Affairs Diabetes Trial

DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011

Standards of Medical Care

explanation for the excess mortality in the

DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011

concept, data from an ancillary study of

cular pathology, such as endothelial dysfunction, are negatively affected by

2-h postmeal 120 mg/dl (6.7

premeal, bedtime, and overnight glucose 60 99 mg/dl (3.35.4 mmol/l)

D. Pharmacologic and overall

type 1 diabetes consists of the following

DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011

Standards of Medical Care

model working in collaboration with

DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011

F. Medical nutrition therapy

Recommendations for primary

MNT is an integral component of diabetes

volvement of the person with prediabetes

lar events in subjects with type 2 diabetes.